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MODERN    DENTAL  MATERIA    MEDICA, 
PHARMACOLOGY  AND  THERAPEUTICS 

BUCKLEY 


Copyright,  1909,  by  P.  Blakiston's  Son  &  Co. 

Copyright,  19 10,  by  P.  Blakiston's  Son  &  Co. 

Copyright,  191  i,  by  P.  Blakiston's  Son  &  Co. 

Reprinted,  October,  1911;    June,  1912;    April,  1913;    October,  1913;     November,  1914; 

June,  1915;     November,  1915;    January,  September  and  October,  1916. 

Copyright,  1917,  by  P.  Blakiston's  Son  &  Co. 
Printed,  April,  19 17. 
Reprinted,  May,  1920. 
Reprinted,  July,  1922. 

"The  use  in  this  volume  of  certain  portions  of  the  text  of  the  United  States 
Pharmacopceia  is  by  virtue  of  permission  received  from  the  Board  of  Trus- 
tees of  the  United  States  Pharmacopoeial  Convention.  The  said  Board  of 
Trustees  is  not  responsible  for  any  inaccuracy  nor  for  any  errors  in  the 
statement  of  quantities  or  percentage  strengths." 

"Permission  to  use  for  comment  parts  of  the  text  of  the  National  Formu- 
lary, Fourth  Edition,  in  this  volume,  has  been  granted  by  the  Committee  on 
Publication  by  authority  of  the  Council  of  the  American  Pharmaceutical 
Association." 


K7 


\S7.^ 


THE     M.4.PI,E     PRESS     X  O  K  K    PA 


TO 

THE    MEMORY    OF 

MY    MOTHER. 

WHOSE   ENCOURAGEMENT  IN   MY  BOYHOOD   DAYS 

SERVED   ME   SO   WELL, 

AND   TO 

MY    WIFE, 

FOR   MANY    WILLING   SACRIFICES   DURING  THE 

PAST   EIGHTEEN   YEARS, 

THIS  VOLUME   IS   FONDLY 

DEDICATED. 


PREFACE  TO  THE  FOURTH  EDITION 


This  book  has  been  rewritten  and  thoroughly  revised;  Part  I 
in  accordance  with  the  United  States  Pharmacopeia  IX,  which  be- 
came ofi&cial  on  September  i,  1916;  and  Part  II  in  accordance  with 
the  knowledge  of  to-day  relating  to  the  treatment  of  diseases  of  the 
teeth  and  associated  structures. 

The  U.S.P.  IX  has  discarded  the  term  cubic  centimeter  (abbrev. 
c.c.)  on  the  ground  that  the  United  States  Bureau  of  Standards 
declared  the  term  a  misnomer,  there  being  a  shght  difference  be- 
tween the  thousandth  part  of  a  liter  and  a  cubic  centimeter.  The 
word  mil,  the  first  three  letters  of  the  whole  word  milUliter,  has  been 
adopted;  therefore,  in  this  work  the  word  mil  is  used  instead  of  c.c. 

The  National  Formulary  is  referred  to  in  this  edition  more  than 
was  done  heretofore,  for  the  reason  that  many  valuable  pharmaceu- 
tical preparations  have  been  omitted  from  the  U.S.P.  IX,  and  are  found 
in  the  N.F.  The  laws  passed  by  various  States  of  the  Union,  in  con- 
formity with  the  National  Food  and  Drugs  Act  which  was  passed  by 
Congress  on  June  30,  1906,  make  both  the  United  States  Phar- 
macopeia and  the  National  Formulary  the  standards  for  drugs. 

An  effort  is  being  made  in  the  profession  of  dentistry  to-day  to 
treat  teeth  under  as  nearly  aseptic  conditions  as  possible.  With 
this  end  in  view  an  article  on  Dental  Sterilization  has  been  written; 
as  has  also  an  article  on  Biologic  Products.  The  advanced  therapy 
of  many  infectious  diseases  includes  the  intelligent  use  of  products 
from  the  Biologic  Laboratories.  Many  of  the  systemic  diseases  of 
this  character  are  now  known  to  have  a  direct  relation  to  diseased 
mouth  and  throat  conditions;  therefore,  it  is  important  that  the 
student  and  the  practitioner  of  dentistry  understand  the  principles 
upon  which  this  therapy  is  based. 

It  will  be  found  that  Part  II,  which  deals  with  Dental  Thera- 
peutics, is  more  profusely  illustrated  than  in  former  editions.  There 
is  no  problem  in  dentistry  at  the  present  time  of  greater  importance 
than  the  treatment  of  pulpless  teeth  and  their  sequelae.  On  this 
particular  subject  many  illustrations  have  been  added  which  show 
results  of  the  treatment  after  the  methods  described  in  the  text. 

The  colored  illustrations,  especially  those  relating  to  the  diseases 
of  the  soft  tissues  of  the  mouth,  will  aid  greatly  in  the  recognition 
of  these  diseases  as  they  present  in  practice. 


viii  PREFACE 

The  author  is  indebted  to  Prof.  John  F.  Biddle,  of  the  Dental 
Department  of  the  University  of  Pittsburg,  for  illustrated  cases  in 
his  practice;  and  also  desires  again  to  record  his  appreciation  of  the 
cordial  reception  which  this  book  has  received  from  dental  teachers 
of  the  subject,  and  from  the  profession  at  large. 

Chicago.  J-   ?•   BuCKLEY. 


PREFACE  TO  THE  THIRD  EDITION 


The  printing  of  the  third  edition  in  twenty  months  after  the  first 
appearance  of  this  book  has  enabled  the  author  to  again  make  such 
alterations  and  corrections  as  would  enhance  the  value  of  the  work. 
The  text  has  been  changed  slightly  throughout  and  several  new  and 
original  illustrations  have  been  added.  The  greatest  change  has  been 
made  in  the  treatment  of  chronic  alveolar  abscess.  Dentists  in  the 
past  have  placed  too  much  dependence  in  drugs  as  the  means  of  cor- 
recting root  and  bone  comphcations;  and,  as  a  result,  many  teeth, 
thus  diseased,  have  been  needlessly  extracted.  Therefore  the  sur- 
gical treatment  of  these  complicated  conditions  has  been  considered 
more  fully  and  new  illustrations  added  to  aid  in  both  the  diagnosis 
and  treatment.  It  has  been  my  desire  to  improve  the  book  without 
enlarging  it,  and  to  make  the  text  still  more  clear,  direct  and  practical. 
Chicago.  J-   P-  BuCKLEY. 


PREFACE  TO  THE  FIRST  EDITION 


The  general  plan  of  tliis  book  is  the  outgrowth  of  many  years 
of  experience  as  a  dental  practitioner  and  teacher  of  Materia  Medica, 
Pharmacology  and  Therapeutics  in  dental  colleges.  During  these 
years,  the  author  has  realized  the  need  of  a  text-book  which  would 
meet  the  wants  of  teacher,  student  and  practitioner. 

The  book  is  intended  to  include  all  that  a  dentist  should  know 
about  drugs  and  remedies  and  their  practical  appHcation  in  the  treat- 
ment of  disease. 

The  work  is  divided  into  two  parts.  The  first  is  devoted  to 
Materia  Medica  and  Pharmacology,  with  enough  Therapeutics  to 
indicate  clearly  the  uses  of  the  various  drugs  and  remedies;  and  an 
effort  has  been  made  to  include  herein  every  drug  or  remedy  which 
is  employed  in  Dental  Therapeutics,  except  those  which  are  obsolete, 
untried  or  savor  of  the  "secret  formula"  variety.  To  accomplish 
this  end,  it  was,  of  course,  necessary  to  consult  freely  the  United 
States  Pharmacopeia,  and  other  standard  works  on  these  subjects. 

Drugs  marked  with  an  asterisk  (*)  mean  that  the  drug  is  a 
member  of  the  group  under  consideration,  but  because  of  other  prop- 
erties which  the  agent  possesses,  it  has  been  elsewhere  considered. 
In  most  instances,  the  drug  is  discussed  under  the  group  in  which  it 
is  first  mentioned,  and  if  it  is  referred  to  subsequently  in  another 
group,  it  is  there  marked  with  an  asterisk.  For  example,  phenol  is 
mentioned  first  as  a  disinfectant  under  which  group  of  drugs  it  is 
discussed.  Later  it  is  mentioned  in  the  group  of  escharotics,  and  is 
there  marked  with  an  asterisk. 

In  this  part  of  the  book,  also,  is  included  Prescription  Writing 
and  its  associated  subjects — Metrology,  Medical  Latin  and  Incom- 
patibility, all  of  which  have  been  given  the  dignity  and  importance 
they  deserve  in  a  dental  course.  It  will  be  observed  that  no  prescrip- 
tions have  been  written  until  after  Prescription  Writing  has  been 
discussed;  after  which,  however,  no  formula  has  been  mentioned  with- 
out a  correctly  written  prescription  for  the  same.  This  plan  was 
followed  for  the  benefit  of  teachers  and  students  in  dental  colleges. 
Prescriptions,  as  a  rule,  are  confusing,  though  enticing  to  beginners, 
and  questions  naturally  suggest  themselves  in  regard  to  the  various 
signs  and  terms  used.  For  the  teacher  to  attempt  to  explain  these 
before  the  subject  proper  had  been  studied  would  be  a  loss  of  time, 
as  no  one  can  write  a  prescription  intelligently  without  first  being 


XU  PREFACE 

familiar  with  drugs.  Therefore,  it  is  better,  in  the  author's  opinion* 
to  avoid  even  the  suggestion  of  questions  pertaining  to  prescriptions 
at  this  time.  By  thus  deferring  the  study  of  Prescription  Writing 
to  about  the  close  of  the  Junior  year,  an  excellent  opportunity  is 
afforded  for  practice  work  throughout  the  entire  Senior  year  when 
Practical  Therapeutics  is  taught.  By  this  means  only  can  students 
become  good  prescription  writers — a  faculty  not  developed  by  the 
average  dentist. 

The  second  part  of  the  book  is  devoted  to  Practical  Dental  Thera- 
peutics. In  writing  it  the  author  was  actuated  by  the  belief  that 
Dental  Therapeutics  is  of  sufficient  importance  to  occupy  a  place  in 
dentistry  by  itself.  It  is  to  be  hoped  that  this  subject  may  ulti- 
mately be  divorced  from  Operative  Dentistry,  to  which  it  has  long 
been  subordinated. 

No  attempt  has  been  made  to  describe  all  of  the  many  methods 
of  treatment,  nor  to  give  the  endless  formulas  suggested  in  the  vari- 
ous text-books  and  journals,  for  the  pathologic  conditions  mentioned 
herein.  To  do  so  would  lead  to  confusion,  as  well  as  make  the  book 
unnecessarily  voluminous,  in  which  case  the  word  "practical"  in 
connection  \\"ith  "therapeutics,"  as  used  here,  would  be  a  misnomer. 
Therefore,  in  most  instances,  only  the  methods  by  which  the  condi- 
tions are  treated  in  the  author's  own  practice  are  detailed.  These 
methods,  of  course,  are  not  wholly  original.  They  have  been  gleaned 
from  clinical  experience,  from  extensive  reading,  and  from  observa- 
tion and  association  with  other  practitioners;  and  in  both  private 
and  infirmary  practice  they  have  given  good  results. 

The  prescriptions  for  remedies,  for  the  most  part,  are  original 
with  the  author,  and  have  been  worked  out  along  the  lines  of  practi- 
cal pharmacy  and  therapeutics.  Where  the  formulas  are  not  original, 
due  credit,  so  far  as  is  known,  has  been  given. 

It  is  unnecessary  to  profusely  illustrate  a  book  of  this  kind.  Only 
such  illustrations  as  will  tend  to  better  explain  the  subject  matter  of 
the  text  are  given.  These,  with  few  exceptions,  were  taken  from 
actual  cases  in  the  author's  practice,  or  from  private  patients  referred 
to  him  for  treatment. 

The  author  desires  to  express  his  grateful  appreciation  to  Dr.  E. 
W.  Elliot  for  valuable  suggestions,  to  Dr.  Lee  K.  Stewart  for  furnish- 
ing models  to  illustrate  a  practical  retaining  appliance,  and  to  other 
professional  friends  for  the  encouragement  given  in  undertaking  the 
work.  He  further  records  his  appreciation  of  the  publisher's  unfail- 
ing courtesy.  J.  P.  Buckley. 

Chicago. 


CONTENTS 


PART  I 

DENTAL  MATERIA  MEDICA  AND  PHARMACOLOGY 

Modern  Dental  Materia  Medica,  Pharmacology  and  Therapeutics,  i 
General  Considerations,  i 

Sources  of  Drugs  and  Constituents  of  Those  of  Vegetable  Origin,  4 
Parts  of  Plants  Used  for  Drugs,  7 
Pharmaceutic  Preparations,  8 

The  Solutions,  8 

The  Mixtures,  11 

Products  by  Extraction,  12 

Mixtures  of  Solids,  16 

Preparations  for  External  Use,  18 

Miscellaneous  List  of  Nonofificial  Bandages,  Splints,  Medicated  and 
Antiseptic  Dressings,  and  Medicated  Gauzes,  20 
Methods  of  Administering  or  Applying  Drugs,  21 

By  the  Mouth,  21 

Hypodermic,  22 

Epidermic  or  Inunction,  25 

Intravenous,  26 

Cataphoresis,  26 

By  the  Rectum,  26 

Inhalation,  26 
Conditions  Modifying  the  Action  and  Effect  of  Drugs,  27 

Habit,  27 

Idiosyncrasy,  27 
Tolerance,  27 

Cumulative  Effect,  28 

Dosage  or  Posology,  28 

Age  and  Sex,  28 

Pathologic  Conditions,  29 

Method  and  Time  of  Administration,  29 
Classification  of  Medicines,  29 
Definitions  of  Remedies,  30 
=^s^__^___^_Foods,  Hematics,  and  Tonics,  34 
DnigsTs^ST""^" 

Local  Remedies,  36 

Antacids,  36 

Antiseptics,  Disinfectants,  and  Deodorants,  41 

Astringents,  Styptics,  and  Hemostatics,  72 

Other  Silver  Salts  and  Soluble  Compounds,  87 

Bleachers,  88 

Oxidizing  Agents,  88 


XIV  CONTENTS 

Escharotics  or  Caustics,  93 
Irritants  and  Counterirritants,  106 
Emollients,  Demulcents,  and  Protectives,  115 
Local  Anesthetics,  126 

Refrigerant  and  Paralyzant,  126 
General  Anesthetics,  140 
Antipyretics,  145 
Hypnotics,  150 
Narcotics,  156 
Stimulants,  163 
Cardiac,  163 
Respiratory,  175 
Gastric,  177 

Miscellaneous  Group,  179 
Alteratives  and  Restoratives,  181 
Digestants,  205 
Cathartics,  208 
Diuretics,  222 
Diaphoretics,  228 
Emetics,  230 
Expectorants,  234 
Sialogogues,  236 

Carminatives,  237  , 

Flavoring  Agents,  240 
Biologic  Products,  245 
Antitoxins,  246 
Serums,  247 
Vaccines,  248 
Remedies  Other  Than  Drugs,  249 
Heat,  249 
Cold,  250 

Compressed  Air,  251 
Light,  251 

Rontgen  or  X-ray,  252 
Radium,  253 
Electricity,  253 
Massage,  254 
Suction,  254 
Suggestion,  255 
Metrology,  257 

The  Metric  System,  259 

Equivalents  to  the  English  Weights  and  Measures,  261 
-Percentage  in  Solutions,  263 
Prescription-writing,  264 
Medical  Latin,  268 

Examples  of  Practical  Prescriptions,  270 
Incompatibility  in  Prescriptions,  274 
Antagonism  of  Drugs,  276 
Dental  Sterilization,  277 

General  Considerations,  277 
Methods  of  Dental  Sterilization,  277 
Direct  Flame,  277 
Moist  and  Dry  Heat,  278 
Chemic  Agents,  278 


CONTENTS  XV 

PART  II 

PRACTICAL  DENTAL  THERAPEUTICS 

General  Considerations,  281 

Diseases  of  the  Hard  Tissues  of  the  Mouth  and  Associated  Structures,  283 
Hypersensitive  Dentin,  283 

General  Considerations,  283 

Previous  Attempts  at  Controlling  Pain,  284 
Therapeutics,  285 

I.  Physical  Agents,  285 

Heat,  285 
Cold,  286 
Light;  Electricity,  287 

II.  Escharotics  or  Caustics,  287 

Phenol  and  Zinc  Chlorid,  287 

Trichloracetic  Acid,  Silver  Nitrate,  and  Trioxymethylen,  288 

III.  Local  Anodynes  or  Local  Anesthetics,  289 
Cocain,  289 

Novocain,  290 

Neothesin,    Menthol,   Oil  of   Cloves,   Eugenol,   Phenol,   Ethyl 
•  Chlorid,  Ether,  and  Chloroform,  291 

IV.  General  Anodynes  or  Analgesics,  291 

Opium,  the  Bromids,  Nitrous  Oxid,  and  Chloroform,  992 
Desensitizing  Paste,  293 

Physiologic  Action,  293 
Indications,  294 
Making  the  Apphcation,  294 
Precautions,  295 

Caution  in  Relation  to  Diseased  Pulps,  296 
Diagnosis  and  Treatment  of  Diseases  of  the  Dental  Pulp;  including    the 
Destruction  and  Removal  of  the  Organ,  298 
General  Considerations,  298 

The  Normal  Dental  Pulp,  298 
Character  of  Blood-vessels,  299 
Common  Soiirces  of  Irritation,  299 
Constructive  Diseases,  302 
Secondary  Dentin,  302 
Pulp  Nodules,  303 
Destructive  Diseases,  306 

Diagnosis  of  Active  and  Passive  Hyperemia  and  True  Pulpitis,  307 
Differential  Diagnosis,  308 
Treatment  of  Active  Hyperemia,  308 
Factors  to  be  Considered  in  Pulp  Capping,  308 
Exceptional  Cases  of  Exposvire,  309 
Therapeutics  of  Pulp  Capping,  310 
Precautions,  310 
Technic,  311 
Treatment  of  Passive  Hyperemia  and  True  Inflammation,  313 
The  Removal  of  Vital  Pulps  and  Subsequent  Treatment,  314 
General  Considerations,  314 

General  Factors  to  be  Observed  in  Removal  of  Pulp,  315 
I.  Anesthetization,  315 

I.  Pressure  Anesthesia,  315 
Sterilization,  315 


XVI  CONTENTS 

The  Solution,  317 

Pressiire,  318 

Confining  the  Solution  under  Pressure,  319 

Opening  the  Pulp  Chamber  to  Expose  Canals,  319 

Selecting  and  Testing  Broaches,  320 

Control  of  Ordinary  Hemorrhage  and  Removal  of  Blood,  320 

Small  Canals,  321 

After-treatment,  322 

When  to  Fill  Canals,  322 

Excessive  Hemorrhage,  323 

Objections  to  the  Use  of  Adrenalin  Chlorid,  323 
2.  Cataphoresis,  324 
II.  Devitalization,  325 
The  Preparation,  326 
Technic  of  Application,  327 

Length  of  Time  Application  Should  Remain,  328 
Opening  Pulp  Chamber  and  Exposing  Canals,  328 
Objections  to  the  Use  of  Dialysed  Iron  and  Tannic  Acid,  329 
Complications,  330 

Hypertrophied  Gum  Tissue,  330 

Diagnosis  as  to  the  Kind  of  Tissue  in  Cavity,  331 

Hypertrophied  Pulp  Tissue,  332 

Secondary  Dentin,  Pulp  Nodules,  and  Pulp  Calcification,  332 
Removal  of  Pulps  from  Deciduous  Teeth,  333 
Arsenical  Poisoning,  334 
Diagnosis  and  Treatment  of  Pulpless  Teeth  and  their  Sequelae;  including  the 

Preparation  of  the  Canals  for  Filling,  336 
General  Considerations,  336 
Coagulating  Drugs,  336 

Important  Products  of  Pulp  Decomposition,  337 
Drugs  Indicated,  337 
Factors  to  be  Considered,  338 
Diagnosis  of  Dead  Pvilps,  338 
Treatment  of  Pulpless  Teeth,  339 

Potassium  and  Sodium,  340 

Technic  of  Using  Schreier's  Alloy,  341 

Rationale  of  Rhein's  Method,  341 

Advantages  of  Phenolsulphonic  Acid,  343 

Caution  in  Using  Callahan's  Method,  344 

Technic  of  Using  Acid  Method,  344 

Nonpurulent  Variety,  345 

Removing  old  Root  Filling,  346 

Removing  Blockade  in  Canal,  347 

Purulent  Variety,  347 

Ionization,  347 

Ionic  Theory,  348 

Complications,  349 

Badly  Decayed  Root,  349 

Pulp  Partially  Alive,  Pulpal  Abscess,  Dry  Gangrene,  350     ■ 
History  and  Treatment  of  Practical  Cases,  351 
Diagnosis  and  Treatment  of  Nonseptic  Pericementitis,  358 
General  Considerations,  358 
Drug  Irritants,  358 
Mechanical  Irritants,  360 
Treatment  of  Nonseptic  Pericementitis,  361 


CONTENTS  XVU 

Diagnosis    and   Treatment    of    Septic    Pericementitis    and    Acute    Alveolar 
Abscess,  364 
General  Considerations,  364 
Local  Treatment,  364 
General  Treatment,  365 
The  Question  of  Extraction,  368 
Chronic  Alveolar  Abscess,  370 
General  Considerations,  270 

1.  Abscess  without  Sinus,  370 

Disposing  of  the  Pus,  370 
Therapeutics,  370 
Weeping  of  Serum,  371 
Complications,  372 

2.  Abscess  with  Sinus,  373 

Therapeutics,  373 

Establishing  Sinus  and  Disposing  of  Pus,  374 
Cauterizing  Sinus,  374 
Complications,  376 

1.  Denuded  End  of  Root,  377 

2.  Resorbed  or  Roughened  End  of  Root,  378 

3.  Encystment  of  Root,  378 

4.  Involving  Bone,  378 

5.  Extensive  Caries  or  Necrosis,  379 

6.  Involving  Vault,  380 

7.  Secondary  Abscess  Pocket,  381 

8.  Involving  Two  or  More  Teeth,  381 

9.  Involving  Antrum,  382 

Periapical  Cysts,  382 
Surgical  Treatment  of  Chronic  Alveolar  Abscesses  and  Their  Sequelae,  382 

Indications  for  Surgery,  382 

The  Anesthetic;  Incision  and  Control  of  Hemorrhage,  383 

Exposing  the  Area  Involved,  385 

Curetting  the  Area,  386 

Filling  End  of  Root,  386 

Washing  and  Packing  the  Wound,  386 

Subsequent  Treatment,  387 
Treatment  of  Gangrenous  Pulps  and  Abscesses  in  Deciduous  Teeth,  390 
Pericemental  Abscess,  391 

Therapeutics,  391 
Filling  Root-canals,  394 
Precautions,  396 
Callahan's  Rosin  Solution,  400 
Technic,  400 
Discolored  Teeth,  402 

Principle  of  Bleaching,  403 
Methods  of  Bleaching,  404 

Oxidation,  404 

Reduction,  405 

Using  Sodium  Dioxid,  405 

Preparation  of  the  Tooth,  406 

Ethereal  Solution  of  Hydrogen  Dioxid,  407 
Antrum  of  Highmore,  410 

Causes  of  Diseases  of  the  Antrum,  410 
Diagnosis,  412 


XVlll  CONTENTS 

Therapeutics,  413 

Surgical  Treatment,  413        ■ 
Medicinal  Treatment,  414 
Pyorrhea  Alveolaris,  416 
Probable  Causes,  416 
Systemic  Effects,  417 
Description  of  Classes,  419 
Therapeutics,  422 

Surgical  Treatment,  423 
Medicinal  Treatment,  42S 

Astringent  Mouth-washes  Contraindicated,  429 
Mechanical  Treatment,  440 
Neuralgia,  444 

Facial  Neuralgia,  445 
Therapeutics,  445 

Medicinal  Treatment,  447 
Local,  447 
General,  448 
Surgical  Treatment,  451 
Tic  Douloureux,  451 
Diagnosis  and  Treatment  of  Diseases  of  the  Soft  Tissues  of  the  Mouth  not  Directly 
Associated  with  the  Teeth,  453 
General  Considerations,  453 
Canker  Sores,  454 
Herpes  Labialis,  455 
Syphilis,  455 

Primary,  456 
Secondary,  458 
Tertiary,  460 
Mercurial  Stomatitis,  461 
Tuberculosis,  462 
Leucoplakia  Buccalis,  463 
Actinomycosis,  464 
Acute  Ulcerous  Gingivitis,  464 
Ludwig's  Angina,  466 
Gonorrhea,  466 
Examination  of  Urine,  468 

Total  Solids  in  Normal  Urine,  469 
Urine  Analysis,  471 
Fehling's  Solution,  471 
General  Index,  473 


PART  I 

MODERN  DENTAL  MATERIA  MEDICA,   PHARMACOLOGY 
AND  THERAPEUTICS 

Materia  medica  is  the  science  that  treats  of  drugs,  the  study 
of  which  includes  the  source,  constituents,  physical  and  chemic 
properties  of  the  inorganic  and  organic  materials  used  for  drugs. 

Pharmacology  is  the  science  that  treats  of  the  action  of  drugs 
upon  the  tissues,  organs  and  functions  of  the  body.  It  is,  therefore, 
the  study  of  the  changes  induced  in  Hving  organisms  by  the  adminis- 
tration of  such  substances  as  do  not  act  as  foods.  Formerly  this 
science  was  called  Pharmacodynamics.  That  part  of  Pharmacology 
devoted  to  the  study  of  Poisons  is  called  Toxicology. 

Therapeutics  is  the  science  that  deals  with  the  application  of 
drugs  or  remedies  to  the  treatment  of  disease. 

The  treatment  of  disease  based  solely  on  cHnical  experience, 
whereby  remedies  are  administered  or  applied  without  reference  to 
their  physiologic  action,  is  known  as  empirical  therapeutics.  The 
application  of  the  essential  oils  to  ike  canals  of  teeth  contaming 
gangrenous  (putrescent)  pulps,  or  the  giving  of  salicyHc  acid,  sodium 
salicylate  or  the  lithium  salts  in  cases  of  pyorrhea  alveolaris,  sup- 
posed to  be  associated  with  rheumatism  or  gout,  are  examples  of 
empirical  therapeutics. 

The  treatment  of  disease  by  the  employment  of  drugs  which, 
from  a  knowledge  of  their  physiologic  actions,  are  expected  to 
counteract  certam  known  pathologic  conditions,  is  recognized  as 
rational  therapeutics.  The  application  of  remedies  containing  for- 
maldehyd  to  a  gangrenous  root-canal,  wherein  it  is  expected  that 
the  formaldehyd  gas  will  neutralize  the  gaseous  end-products  of 
pulp  decomposition,  may  be  given  as  an  illustration  of  rational 
therapeutics. 

While  it  is  essential  that  the  student  should  understand  at  the 
very  outset  the  definition  of  the  terms  materia  medica,  pharmacology 
and  therapeutics,  it  is  also  essential  that  other  general  terms  used 
throughout  the  text  should  be  thoroughly  mastered  at  this  time. 
A  medicine  is  any  substance  used  in  the  treatment  of  disease. 

A  drug  is  any  substance  which  may  be  used  as  a  medicine,  or 


2  DEFINITIOX    OF    TERMS 

it  may  be  used  purely  in  chemic  processes  and  not  directly  in  the 
treatment  of  disease. 

A  remedy  is  a  broader  term  and  includes,  besides  material  sub- 
stances, such  agents  or  means  employed  in  therapeutics  as  heat,  cold, 
light,  electricity,  massage  and  suggestion.  Remedies,  therefore,  may 
be  di\'ided  as  follows: 

Prophylactic  Remedies. — Those  used  to  prevent  disease,  as 

polishing   tooth-surfaces   to   prevent   caries,    or   vaccination 

to  prevent  smallpox. 

Hygienic  Remedies. — Those  that  assist  in  the  maintenance 

of  health,  such  as  pure  air,  water,  food  and  bathing. 

Imponderable   Remedies. — These    include    heat,    cold,    Hght, 

electricity,  massage  and  suggestion. 

Mechanical  Remedies. — These  involve  the  use  of  bandages, 

spHnts,  instruments,  etc. 

Pharmacologic   Remedies. — These    are    called    also    medicinal 

remedies  and  are  the  material  substances  or  medicines  used 

in  the  treatment  of  disease. 

Biologic    Remedies. — These    are    bacteriologic    and    chemic 

products  obtained  from  the  biologic  laboratories,   and  are 

known  as  serums,  vaccines  and  antitoxins. 

There  are  several  closely  related  terms  employed  in  the  study  of 
the  practical  uses  of  remedies,  which  often  lead  to  confusion.  It  is 
well  that  the  student  understand  these  terms  at  the  very  outset. 
The  term  specific  has  a  double  meaning.  When  used  in  connection 
with  a  remedy  it  means  that  the  remedy,  if  used  in  the  proper 
manner,  can  generally  be  depended  upon  to  produce  definite 
results  in  certain  diseases.  For  example,  formocresol  is  a  specific 
for  gangrenous  pulp  conditions;  antitoxin  is  a  specific  for  diph- 
theria. There  are  but  few  specific  remedies.  AppHed  to  a  disease, 
the  term  specific  means  syphilis,  and  it  is  so  used  by  physicians 
and  dentists  to  indicate  that  disease  which  has  associated  with 
it  the  stigma  of  vice.  Therefore,  s}^hins  is  generally  spoken  of  as 
a  specific  disease. 

The  terms  physiologic  action,  physiologic  effect  and  therapeutic 
effect  are  too  frequently  used  interchangeably,  without  reference 
to  their  true  meaning.  There  is  a  distinction  between  the  action 
and  the  effect  of  a  drug.  Many  times  the  action  of  a  drug  is  obscure, 
but  the  effect,  if  produced,  must  necessarily  be  apparent.  This  is 
nicely  illustrated  by  the  inhalation  of  ammonia  in  cases  of  syncope 
(fainting).     The  action  of  the  ammonia  gas  is  that  of  an  irritant  on 


THE    UNITED    STATES   PHARMACOPEIA  3 

the  respiratory  mucous  membrane,  while  the  physiologic  effect  desired 
in  this  instance  is  cardiac  and  respiratory  stimulation.  This  is 
brought  about  reflexly  by  the  local  irritation ;  for  ammonia,  thus  ad- 
ministered, produces  a  marked  increase  in  both  the  strength  and 
rapidity  of  the  pulse  and  the  depth  and  rapidity  of  the  respirations. 
In  the  case  mentioned  above,  the  therapeutic  effect  would  be  the 
return  of  consciousness,  which  might  not  follow  without  further 
treatment.  It  is,  therefore,  possible  to  have  the  physiologic  action 
and  effect  of  a  drug  without  the  therapeutic  effect. 

Resolution  is  a  term  which  indicates  the  return  of  an  abnormal 
to  a  normal  condition,  and  means  structural  recovery.  Dissolution 
is  a  term  which  means  death. 

The  author  desires  here  to  emphasize  the  importance  of  learning 
the  distinction  between  these  several  terms,  for  they  are  too  often 
used  sjmonymously,  without  reference  to  their  true  meaning. 

A  poison  is  any  substance  which,  when  administered  or  applied, 
by  its  inherent  physical  or  chemic  properties  causes  disease  or  death. 
That  branch  of  medical  science  which  treats  of  the  action  and  effects 
of  poisons,  their  detection,  and  the  treatment  of  the  conditions 
resulting  therefrom,  is  called  Toxicology. 

Pharmacy  is  the  art  of  preparing,  compounding  and  dispensing 
medicines. 

The  Pharmacopeia  is  an  authoritative  work  which:  (i)  Estab- 
lishes standards  and  tests  for  the  identification,  quahty,  purity  and 
strength,  and  (2)  gives  directions  for  the  preparation,  purification  and 
preservation  of  drugs  and  medicines.  How  to  prepare,  purify  and 
preserve  medicines  is  the  work  of  the  pharmacist,  but  every  practicing 
dentist  should  be  famihar  with  certain  standards  and  tests  for  the 
identity,  quahty,  purity  and  strength  of  the  medicines  employed  in 
daily  practice. 

The  pharmacopeias  may  be  considered  the  medico-legal  authori- 
ties for  drugs  and  medicines  in  their  respective  countries. 

The  United  States  Pharmacopeia  (abbreviation,  U.S.P.)  is 
prepared  by  a  committee  consisting  of  delegates  appointed  by 
authority  from  regularly  incorporated  medical  and  pharmaceutic 
societies  and  colleges.  This  pharmacopeial  committee  meets  at 
the  beginning  of  each  decade,  and  the  code  of  remedial  agents  thus 
estabhshed  is  intended  to  serve  as  a  standard  until  superseded  by 
a  new  revision.  The  last  (ninth,  ix)  edition  of  the  U.S.P.  became 
the  ofi&cial  standard  September  i,  19 16.  This  book  has  been 
thoroughly  revised  in  accordance  therewith.  By  admitting  certain 
articles  to  the  pages  of  the  U.S.P.,  it  declares  them  to  be   of  sufl&- 


4  SOURCES    OF   DRUGS 

dent  importance  as  to  merit  confidence  in  their  use  in  the  practice 
of  medicine.  Articles  thus  recognized  are  known  as  "official," 
which  is  S3nionymous  with  "pharmacopeial."  This  should  not  be 
taken  to  mean  that  articles  not  admitted  are  valueless,  for  there  are 
many  formulas  in  common  use  to-day  which  are  exceedingly  valuable, 
though  not  ofl&cial. 

National  Formulary  (abbreviation,  N.F.)  is  a  collection  of 
formulas  issued  by  the  American  Pharmaceutical  Association  as 
a  supplement  to  the  United  States  Pharmacopeia. 

Food  and  Drugs  Act  is  a  National  law,  which  was  passed  by 
Congress  on  June  30,  1906.  This  was  soon  followed  by  similar 
legislation  in  the  various  States  of  the  Union.  These  laws  make 
the  United  States  Pharmacopeia  and  the  National  Formulary  the 
standards  for  drugs.     The  National  Act  states: 

"The  term  'drug,'  as  used  in  this  Act,  shall  include  all  medicines 
and  preparations  recognized  in  the  United  States  Pharmacopeia 
or  National  Formulary  for  internal  or  external  use,  and  any  sub- 
stance or  mixture  of  substances  intended  to  be  used  for  the  cure, 
mitigation,  or  prevention  of  disease  of  either  man  or  other  animals." 
This  legislation  has  been  the  means  from  which  a  great  improve- 
ment in  the  quality  of  medicines  has  resulted. 

On  account  of  the  recognition  given  the  National  Formulary 
by  the  Food  and  Drugs  Act,  many  formulas  heretofore  included  in 
the  previous  Pharmacopeias  have  been  omitted  in  the  ninth  edition. 
These  formulas  are  now  found  in  the  National  Formulary;  and 
whenever  occasion  requires,  throughout  this  work,  reference  will 
be  made  to  this  standard  authority,  though  the  official  prepara- 
tions, or  a  combination  of  two  or  more,  will  largely  furnish  the  basis 
for  the  formulas  given  by  the  author  in  that  part  of  the  book  de- 
voted to  practical  therapeutics. 

A  dispensatory  is  a  commentary  on  the  pharmacopeia,  including, 
as  do  the  American  Dispensatories,  all  information  pertaining  to 
the  pharmacy  as  well  as  the  action  and  uses  of  medicines.  Dis- 
pensatories are  private  pubHcations,  and  should  be  used  only  as 
references,  for  they  are  not  intended  to  take  the  place  of  the  standard 
and  legal  authorities — the  Pharmacopeia  and  National  Formulary. 

SOURCES  OF  DRUGS  AND  CONSTITUENTS  OF  THOSE  OF 
VEGETABLE  ORIGIN 

Drugs  are  derived  from  the  three  kingdoms  of  nature — mineral, 
animal  and  vegetable.     Those  which  belong  to  the  mineral  kingdom 


CONSTITUENTS    OF  VEGETABLE   DRUGS  5 

are  called  inorganic  drugs,  and  are  obtained  by  chemic  processes  di- 
rectly from  nature.  Many  valuable  drugs  are  made  by  synthesis — the 
artificial  formation  of  the  product  by  chemically  combining  its  con- 
stituents. Those  so  made  are  known  as  synthetic  drugs.  Organic 
drugs  are  those  which  are  taken  from  the  animal  and  vegetable  king- 
doms. The  element,  carbon,  plays  the  leading  role  in  all  organic 
drugs,  and  is  combined  in  the  compounds  of  carbon  with  such  ele- 
ments as  hydrogen,  oxygen,  nitrogen,  and  others.  A  great  many 
medicinal  products  are  being  produced  by  biologic  processes.  They 
include  the  various  serums,  vaccines  and  antitoxins.  A  serum  for 
therapeutic  use  is  a  product  obtained  from  the  blood  of  an  immunized 
animal.  A  vaccine  is  any  substance  used  for  preventive  inoculation, 
and  is  obtained  in  various  ways — as  lymph  from  a  cowpox  vesicle; 
from  the  patient  himself.  A  vaccine  made  from  a  bacterial  culture 
obtained  from  the  patient  is  known  as  an  autogenous  vaccine.  An 
antitoxin  is  a  counterpoison  or  antidote  elaborated  by  the  body  to 
counteract  the  toxins  of  bacteria.  Antitoxins  are  frequently  used 
in  the  treatment  of  certain  infectious  diseases,  and  also  to  confer 
immunity  against  these  diseases. 

The  constituents  of  vegetable  drugs  of  value  in  medicine  and 
dentistry  are  called  the  active  principles,  and  they  include  carbohy- 
drates, alkaloids,  glucosids,  neutral  principles,  organic  acids,  volatile 
oils,  resins,  gums,  fixed  oils  and  fats,  camphors  and  other  miscellane- 
ous compounds. 

Carbohydrates  are  largely  used  as  foods,  yet  many  of  them,  owing 
to  their  bland  and  soothing  action,  are  employed  as  medicines. 
These  include  starch  and  the  sugars. 

'Alkaloids  are  nitrogenous  compounds,  having  the  reaction  and 
basic  properties  of  alkahes.  They  are  odorless,  have  a  bitter  taste, 
and  generally  possess  powerful  physiologic  actions.  Alkaloids  are 
almost  insoluble  in  water,  but  they  readily  combine  with  acids  to 
form  crystalHzable  salts  which  are  freely  soluble.  For  example, 
cocain  is  an  alkaloid,  and,  as  such,  is  not  largely  used  in  dental  prac- 
tice; but,  when  acted  upon  by  hydrochloric  acid,  cocain  hydrochlorid 
is  formed,  and  this  alkaloidal  salt  is  one  of  our  most  useful  drugs. 

Other  examples  of  alkaloids  are,  strychnin,  morphin,  atropin,  etc. 
The  term  artificial  alkaloid  is  used  to  designate  secondary  alkaloids 
derived  from  natural  ones,  as  apomorphin,  which  is  obtained  by 
abstracting  from  morphin  a  molecule  of  water. 

Glucosids  comprise  those  vegetable  principles  which  may  be 
resolved  by  boiling  with  dilute  acid  or  alkahes,  or  by  the  action  of 
ferments,  into  glucose  and  one  or  more  other  products  peculiar  to  the 


6  SOURCES    OF   DRUGS 

substance  tested.  Glycyrrhizin,  obtained  from  liquorice-root,  and 
salicin,  from  willow-bark,  are  examples. 

Neutral  principles  are  neutral  constituents,  differing  from  alka- 
loids in  not  being  basic  in  character  and  from  glucosids  in  not  being 
resolvable  into  glucose.  Aloin,  from  aloes,  and  piperin,  from  black 
pepper,  are  examples. 

Organic  acids  are  found  in  many  plants,  either  free  or  combined 
with  alkaloids  or  inorganic  bases.  Those  of  most  value  in  dentistry- 
are  acetic,  benzoic,  lactic,  salicylic,  oxalic,  and  tannic  acids. 

Volatile  oils,  also  called  essential  oils,  form  a  large  group  of  organic 
bodies,  from  which  they  are  chiefly  obtained  by  distillation.  They 
are  highly  odorous,  oily,  sparingly  soluble  in  water,  more  or  less 
soluble  in  alcohol  and  ether,  and  prone  to  become  resinous  on  expo- 
sure to  air.  In  the  past  the  volatile  oils  have  occupied  a  prominent 
place  in  dental  practice.  Those  to  be  remembered  are  the  oils  of 
cassia  {cinnamon),  cloves,  peppermint,  winter  green,  turpentine,  eucalyp- 
tus, and  cajuput. 

Resins  are  exudations  associated  with,  and  probably  derived 
from,  volatile  oils.  They  are  insoluble  in  water,  but  freely  soluble  in 
alcohol.  Examples  of  resins  are  those  of  jalap,  podophyllum  and 
common  rosin.  When  a  resin  and  volatile  oil  are  both  constituents 
of  the  same  drug,  the  former  is  held  in  solution  by  the  latter,  making 
a  natural  oleoresin. 

Gums  are  dried  exudations  obtained  by  incising  the  Hmbs  and 
branches  of  certain  plants.  Gums,  contrary  to  resins,  are  insoluble 
in  alcohol,  but  freely  soluble  in  water.  The  most  important  gums  are 
those  of  acacia  and  tragacanth.  Ordinary  mucilage  is  a  solution  of 
certain  gums  in  water. 

Fixed  oils  and  fats  are  obtained  by  simple  pressure,  and  are  not 
readily  volatiHzed.  Those  used  chiefly  in  dentistry  are  lard,  lard 
oil,  olive  oil,  castor  oil,  and  oil  of  theohroma  {cacao  butter). 

Camphors  are  soHd  and  crystalHzable  bodies,  closely  associated 
in  plants  with  ter penes,  i.e.,  compounds  of  carbon  and  hydrogen  in 
the  proportion  CioHie,  and  probably  derived  from  them  by  oxida- 
tion. The  principal  member  of  the  group  is  offlcial  camphor,  CioHieO. 
Stearoptenes,  obtained  from  various  essential  oils,  as  menthol  and 
eucalyptol,  are  sometimes  called  camphors,  but  should  not  be  so 
considered. 

Miscellaneous  compoimds  are  such  proximate  principles  as  are 
not  referable  to  the  groups  mentioned.  They  include  several  com- 
pounds of  value  to  dentistry,  as  eucalyptol,  eugenol,  thymol  and 
guaiacol. 


PARTS    OF   PLANTS   USED    FOR   DRUGS  7 

PARTS  OF  PLANTS  USED  FOR  DRUGS 

The  crude  organic  drugs  which  form  a  large  part  of  the  materia 
medica  are  chiefly  derived  from  the  vegetable  kingdom.  All  the 
different  parts  of  plants  are  used.  The  active  principle  is  often  dis- 
tributed throughout  the  entire  plant,  but  is  generally  found  more 
abundantly  in  one  particular  part,  which  is  then  used.  For  con- 
venience in  study,  the  parts  oj  plants  used  for  drugs  can  be  divided 
into  portions  which  grow  under  and  above  the  ground. 

Portions  Under  Ground. — The  root  {radix)  proper  is  that  part 
of  the  plant-axis  which  does  not  bear  leaves.  Roots  are  ordinarily 
subterranean  (grow  underground)  in  their  habits,  and  serve  the 
double  use  of  attaching  the  plant  securely  to  the  soil  and  of  enabling 
it  to  absorb  from  the  latter  the  necessary-  food.  The  roots  of  some 
plants  not  only  perform  these  functions,  but  become  greatly  thick- 
ened and  serve  also  for  the  accumulation  of  reserve  food  material  and 
are  then  called  tubers  (potato,  beet  and  turnip).  Roots  possess  a 
bark  which  is  sometimes  used  separately  (sassafras).  If  the  under- 
ground portion  of  a  root  does  bear  leaves,  it  is  termed  rhizome  [rhiz- 
oma).  This  is  sometimes  called  a  subterranean  stem.  When  the 
root-leaves  become  enlarged  and  serve  as  storehouses  for  food,  a 
bulb  (bulbus)  is  formed.  The  onion  is  an  example.  The  lowest  part 
of  the  stem  of  a  plant  is  often  thickened,  and  is  then  called  corm 
(cormus) . 

Portions  Above  Ground. — When  the  entire  plant,  except  the  root 
is  employed,  it  is  called  herb  {herba).  This  consists  of  stems,  leaves, 
and  often  flowers  or  fruit. 

The  stem  proper  is  that  part  of  the  plant-axis  which  bears  leaves 
or  some  modification  of  them.  Its  functions  are,  to  form  such  a 
support  for  the  leaves  as  will  duly  expose  them  to  the  influence  of 
light  and  air,  to  bear  the  floral  organs  and  convey  to  them  the  neces- 
sary nutriment,  and  to  form  a  means  of  communication  and  inter- 
change between  the  roots,  or  organs  which  absorb  the  crude  nutritive 
material  from  the  soil,  and  the  leaves,  or  organs  which  assimilate 
this  food.  With  small,  herby  plants  the  stem  is  called  stipes;  with 
larger  plants  it  is  transformed  into  wood  (lignum)  and  is  covered  with 
bark  (cortex).  The  outer  layers  of  the  older  bark  are  always  corky, 
and  a  secondary  bark  develops  inside  of  this  which  is  called  liber. 

The  leaves  (folia)  are  stem-appendages,  regularly  arranged  upon 
the  stem,  and  consist  of  expansions  of  its  tissues.  Buds  may  be  con- 
sidered as  rudimentary  stems,  with  rudimentary  leaves  compactly 
arranged  upon  them. 


8  PHARMACEUTIC   PREPARATIONS 

The  flower  (flos)  is  a  special  modification  of  the  leaves.  It  con- 
sists of  the  calyx  (usually  green  parts  called  sepals)  and  a  corolla. 
The  latter  is  made  up  of  showy  leaflets  (petals)  and  the  inconspicuous, 
but  important,  male  and  female  elements  called  stamens  and  pistil, 
respectively.  The  stamens  bear  the  fertilizing  element  in  the  form 
of  granules,  termed  pollen.  The  pistil  consists  of  the  ovary,  which 
develops  the  seed  {semen),  and  the  style  and  stigma,  which  ser\e  to 
receive  the  pollen.  After  fertilization  takes  place,  the  ovary  develops 
into  the  fruit  (fructus) ;  this  may  also  involve  neighboring  parts,  es- 
pecially the  top  of  the  stem,  as  in  the  apple  and  strawberry.  The 
fruit  consists  of  the  outer  portion,  pericarp,  and  the  seeds.  The  latter 
contain  the  embryo  and  nutriment  material,  and  are  protected  by  a 
more  or  less  hard  shell.  Certain  organic  drugs  consist  of  the  coagu- 
lated juices  of  the  plants  and  show  no  structure  (opium,  etc.) , 

PHARMACEUTIC  PREPARATIONS 

Pharmaceutic  preparations  are  those  preparations  made  by 
pharmacists,  the  formula  and  directions  being  given  for  their  prepara- 
tion in  the  United  States  Pharmacopeia  and  National  Formulary; 
and  nearly  one-half  of  the  articles  of  the  U.S.P.  and  all  in  the  N.F. 
are  pharmaceutic. 

The  pharmaceutic  preparations  of  the  U.S.P.  may  be  classified 
as  follows: 

I.  The  solutions. 
11.  The  mixtures. 

III.  Products  by  extraction. 

IV.  Mixtures  of  solids. 

V.  Preparations  for  external  use. 
These  groups  are  subdivided  into  a  number  of  classes,  each  class 
having  a  distinct  Latin  title  which  officially  designates  its  members, 
or  individual  preparations,  and  by  which  they  are  alphabetically 
arranged  in  the  U.S.P.  Besides  the  Latin  and  EngKsh  titles,  each 
class  is  also  known  by  an  English  name  and  various  synonyms.  In 
the  U.S.P.  IX  the  synonyms  and  official  abbreviations  are  given. 
The  student  will  gradually  become  acquainted  with  the  vari- 
ous classes  and  names  of  each  by  carefully  studying  the  following 
classification : 

I.  THE  SOLUTIONS 

The  general  class  of  pharmaceutic  preparations  called  "The 
Solutions"  includes  nine  subclasses,  each  classified  according  to  the 
solvent  used: 


PHARMACEUTIC   PREPARATIONS  9 

1.  Aromatic  Waters. — ^Aquae  Aromaticae. — Aromatic  waters  are 
solutions  of  volatile  substances  in  water.  •  They  embrace  the  popular 
aqueous  solutions  of  the  volatile  oils,  and  in  these  cases  are  made  by 
first  triturating  the  oil  with  some  insoluble  substance,  as  talc,  pre- 
cipitated calcium  phosphate,  or  magnesium  carbonate,  thus  dividing 
t]ie  globules  of  the  oil  and  distributing  it  over  much  surface,  after 
which  distilled  water,  recently  boiled,  is  added,  when,  by  filtering, 
the  water  abstracts  from  the  mixture  all  of  the  oil  that  it  is  capable 
of  holding  in  solution.  These  aromatic  waters  were  formerly  known 
as  "medicated  waters"  and  are  popular  in  dental  practice.  Unless 
otherwise  directed,  they  should  be  made  by  the  following  general 

process: 

GENERAL  PROCESS,  U.S.P.  IX 

Volatile  Oil,  two  milliliters (2  rails — 30  m.). 

Purified  Talc,  fifteen  grammes (iS-o  Gm. — 3.9  dr.). 

Distilled  Water,  recently  boiled,  one  thousand  milliliters 
(1,000  mils-i  qt.). 

Triturate  the  volatile  oil  with  the  purified  talc,  add  the  recently 
boiled  distilled  water  gradually  with  continued  trituration,  filter, 
and  pass  the  filtrate  through  the  filter  repeatedly  until  the  Aromatic 
Water  is  perfectly  clear. 

The  waters  most  commonly  used  are: 

Ammonia  Water  (Aqua  Ammoniae). 

Camphor  Water  (Aqua  Comphorae). 

Cinnamon  Water  (Aqua  Cinnamomi). 

Distilled  Water  (Aqua  DestUlata). 

DistUled  Water  Sterilized  (Aqua  Destillata  Sterilisata). 

Hamamelis  (witch-hazel)  Water  (Aqua  Hamamelidis) . 

Peppermint  Water  (Aqua  Menthse  Piperitse). 

Rose  Water  (Aqua  Rosae). 

2.  Solutions. — ^Liquores. — These  preparations  are  solutions  of 
non-volatile  substances  in  water.  The  official  solutions  contain  only 
inorganic  salts. 

The  most  important  solutions  are: 

Antiseptic  Solution,  Mouth-wash  (Liquor  Antiseptici,  N.F.). 
Alkaline  Antiseptic  Solution,  Mouth- wash  (Liquor  Antisep- 
tici Alkalini,  N.F.). 

Solution  of  Calcium  Hydroxid,  Lime-water  (Liquor  Calcis). 
Compound  Solution  of  Cresol  (Liquor  Cresolis  Compositus). 
Compound  Solution  of  Chlorin  (Liquor  Chlori  Compositus). 
Solution  of  Ferric  Subsulphate,  Monsel's  Solution  (Liquor 
Ferri  Subsulphatis). 

Solution  of  Formaldehyd,  Formalin  (Liquor  Formaldehydi). 
Solution  of  Hydrogen  Dioxid  (Liquor  Hydrogenii  Dioxidi). 


10  PHARMACEUTIC   PREPARATIONS 

Solution   of  Hypophysis,   Solution  of  the   Pituitary  Body 

(Liquor  Hypophysis). 

Compound  Solution  of  lodin,  Lugol's  Solution  (Liquor  lodi 

Compositus). 

Solution  of  Magnesium  Citrate  (Liquor  Magnesii  Citratis). 

Solution  of  Potassium  Hydroxid  (Liquor  Potassii  Hydroxidi). 

Solution  of  Chlorinated  Soda,  Labarraque's  Solution  (Liquor 

Sodae  Chlorinatae). 

Physiologic  Solution  of  Sodium   Chlorid,   Physiologic    Salt 

Solution  (Liquor  Sodii  Chloridi  Physiologicus). 

Solution  of  Sodium  Hydroxid  (Liquor  Sodii  Hydroxidi). 

Solution  of  Zinc  Chlorid  (Liquor  Zinci  Chloridi). 

3.  Spirits. — Spiritus. — The  spirits  are  solutions  of  volatile  sub- 
stances in  AlcohoL  Several  of  the  oflicial  spirits  are  solutions  of 
essential  oils,  and.  are  frequently  called  "Aromatic  Spirits"  or 
"Essences." 

The  most  important  spirits  are: 

Spirit  of  Ammonia  (Spiritus  Ammonise)  (Nonofficial). 

Aromatic  Spirit  of  Ammonia  (Spiritus  Ammoniae  Aromaticus). 

Brandy  (Spiritus  Vini  Gallici)  (Nonofficial). 

Spirit  of  Camphor  (Spiritus  Camphorae). 

Spirit  of  Cinnamon  (Spiritus  Cinnamomi). 

Compound  Spirits  of  Ether,  Hoffmann's  Anodyne  (Spiritus 

^theris  Compositus). 

Compound  Spirit  of  Juniper  (Spiritus  Juniperi  Compositus). 

Spirit  of  Myrcia,  Bay-rum  (Spiritus  Myrciae)  (Nonofficial). 

Spirit  of  Nitroglycerin,  Spirit  of  Glonoin  (Spiritus  Glycerylis 

Nitratis). 

Spirit  of  Peppermint  (Spiritus  Menthae  Piperitae). 

Whisky  (Spiritus  Frumenti)  (Nonofficial). 

4.  S3niips. — Syrupi. — Syrups  are  nearly  saturated  solutions  of 
sugar  in  water,  in  which  medicinal  or  flavoring  agents  are  dissolved. 
The  most  important  syrups  are: 

Simple  Syrup  (Syrupus)  (85  per  cent.  Sugar). 
Syrup  of  Acacia  (Syrupus  Acaciae). 

Syrup  of  Calcium  Lactophosphate   (Syrupus   Calcii  Lacto- 
phosphatis). 

Syrup  of  Wild  Cherry  (Syrupus  Pruni  Virginianae). 
Syrup  of  Ginger  (Syrupus  Zingiberis). 
Syrup  of  Hypophosphites  (Syrupus  Hypophosphitum) . 
Syrup  of  Ipecac  (Syrupus  Ipecacuanhas). 
Syrup  of  Iron,  Quinin  and  Strychnin  Phosphates  (Syrupus 
Ferri,  Quininae  et  Strychninae  Phosphatum  (Nonofficial). 
Syrup  of  Orange  (Syrupus  Aurantii). 

Compound  Syrup  of  Sarsaparilla  (Syrupus  Sarsaparillae  Com- 
positus). 


PHARMACEUTIC   PREPARATIONS  II 

Compound   Syrup   of   Squill,   Hive   Syrup   (Syrupus   Scillse 

Compositus). 

Syrup  of  Senna  (Syrupus  Sennse). 

Syrup  of  Tolu  (Syrupus  Tolutanus). 

5.  Honeys. — ^Mellita. — Honeys  are  solutions  of  certain  substances 
in  clarified  honey.     Honey  of  rose  (mel  rosae)  is  an  example. 

6.  Elixirs. — Elixiria. — EHxirs  are  solutions  containing  aromatic 
substances,  sugar,  alcohol,  and  water.  They  are  used  largely  to 
mask  the  taste  of  nauseating  drugs.  There  are  only  two  ofi&cial 
elixirs : 

Aromatic  Elixir,  Simple  Elixir  (Elixir  Aroma  ticum). 
Elixir  of  Glycyrrhiza,  Elixir  of  Licorice  (Elixir  Glycyrrhizae). 
Elixir  of  Iron,  Quinin  and  Strychnin  Phosphates  (Elixir  Ferri, 
Quininas  et  Strychninae  Phosphatum)  (Nonofi&cial). 

7.  Glycerites. — Glycerita. — Glycerites  are  solutions  of  medicinal 
substances  in  glycerin.     The  most  important  glycerites  are: 

Glycerite  of  Boroglycerin  (Glyceritum  Boroglycerini). 
Glycerite  of  Iron,  Quinin  and  Strychnin  Phosphates  (Glyceri- 
tum Ferri,  Quininae  et  Strychninae  Phosphatum)  (Nonofi&cial). 
Glycerite  of  Phenol,  Glycerite  of  Carbolic  Acid  (Glyceritum 
Phenolis). 

Glycerite  of  Starch  (Glyceritum  Amyli). 
Glycerite  of  Tannic  Acid  (Glyceritum  Acidi  Tannici). 

8.  Oleates. — Oleata. — Oleates  are  solutions  of  metallic  oxids  or 
alkaloids  in  oleic  acid.     The  useful  oleates  are : 

Oleate  of  Cocain  (Oleatum  Cocainae)  (Nonofificial). 
Oleate  of  Mercury  (Oleatum  Hydrargyri). 

9.  Collodions. — Collodia. — Collodions  are  solutions  of  medicinal 
substances  in  collodion,  i.e.,  gun-cotton  (pyroxyhn)  dissolved  in  ether 
and  alcohol.  These  preparations  are  used  externally,  and  chiefly 
as  protectants.     The  important  collodions  are: 

Collodion  (Collodium).  ^ 

Cantharidal  Collodion,  Blistering  Collodion  (Collodium  Can- 

tharidatum). 

Flexile  Collodion  (Collodium  Flexile). 

Styptic  Collodion  (20  per  cent.  Tannic  Acid)  (Collodium  Stypticum) 

(Nonofficial). 

n.  THE  MIXTURES 

This  general  class  of  pharmaceutic  preparations  includes  such 
liquid  preparations  as  are  not  clear  solutions,  or  solutions  that  can- 
not be  classified  according  to  the  solvent  used.  There  are  three 
subclasses: 


12  PHARMACEUTIC    PREPARATIONS 

1.  Mixtures. — ^Misturae. — Mixtures  are  liquid  preparations  usu- 
ally holding  in  suspension  in  water  some  insoluble  substance.  Mix- 
tures should  be  well  shaken  before  being  administered.  Examples 
of  official  mixtures  are: 

Chalk  Mixture  (Mistura  Cretae). 

Compound  Mixture  of  Glycyrrhiza,  Brown  Mixture  (Mistura 

Glycyrrhizae  Composita). 

2.  Emulsions.— Emulsa. — Emulsions  are  liquid  preparations 
consisting  of  oily,  fatty,  resinous,  or  otherwise  insoluble  substances, 
suspended  in  water  by  the  aid  of  some  gum  or  mucilage  called  the 
emulsifying  agent,  as  acacia  or  tragacanth.  Milk  and  the  yolk  of 
egg  are  natural  emulsions.     The  important  official  emulsions  are: 

Emulsion  of  Cod-liver  Oil  (Emulsum  Olei  Morrhuae). 
Emvdsion  of  Oil  of  Turpentine  (Emulsum  Olei  Terebinthinag), 

3.  Liniments. — Linimenta. — These  are  liquid  preparations  for 
external  use,  consisting  of  solutions  of  oily  or  resinous  constituents 
in  alcohol  or  oils,  or  mixtures  of  liquid  soaps.  With  the  exception 
of  belladonna  liniment  and  lime  liniment,  which  are  used  as  seda- 
tive applications,  all  the  official  liniments  are  of  a  stimulating 
character,  and  should  be  applied  with  friction  or  massage.  The 
useful  official  liniments  are: 

Belladonna  Liniment  (Linimentum  Belladonnae). 

Lime  Liniment,  Carron  Oil  (Linimentum  Calcis). 

Camphor  Liniment  (Linimentum  Camphorae). 

Liniment  of  Soft  Soap,  Tincture  of  Green  Soap  (Linimentum 

Saponis  MoUis). 

m.  PRODUCTS  BY  EXTRACTION^ 

The  medicinal  constituents,  called  active  principles,  of  crude 
drugs  are  obtained  by  extraction.  The  Hquid  used  is  termed  the 
menstruum,  and  may  be  water  or  alcohol  or  both  in  varying  propor- 
tions, with  sometimes  the  addition  of  glycerin.  This  general  class 
is  represented  by  nine  subclasses. 

1.  Mucilages.— Mucilagines. — These  are  solutions  of  gums  or 
other  mucilaginous  constituents  of  vegetable  drugs  extracted  with 
an  aqueous  menstruum.     They  are  used  as  emollients,  as  emulsify- 

^The  U.S. P.  formerly  recognized  a  class  of  preparations  known  as  "Wines"  under 
"Products  by  Extraction."  This  class  has  been  dropped  in  the  U.S.P.  IX.  It  is 
there  stated  that  wine  as  a  menstruum  or  solvent  can  with  advantage  be  replaced  by 
alcohol  of  various  strengths,  and  the  uncertainties  due  to  the  variability  in  quality 
and  alcoholic  content  of  the  wines  of  commerce  are  avoided.  Wines,  therefore,  will 
not  be  discussed  here. 


PHARMACEUTIC   PREPARATIONS  1 3 

ing  agents  for  suspending  insoluble  substances  in  liquids,  and  as 
excipients  for  pills. 
•  The  important  mucilages  are: 

Mucilage  of  Acacia  (Mucilago  Acaciae). 

Mucilage  of  Sassafras  Pith  (Mucilago  Sassafras  Medullae) 

(Nonofi&cial). 

Mucilage  of  Tragacanth  (Mucilago  Tragacanthae). 

Mucilage  of  Elm  (Mucilago  Ulmi)  (Nonofl6cial). 

2.  Infusions. — ^Infusa. — ^Infusions  are  liquid  preparations  made 
by  pouring  boiling  water  on  vegetable  drugs  in  a  suitable  vessel 
provided  with  a  cover,  allowing  it  to  stand  for  half  an  hour,  and  then 
straining.  Tea,  if  properly  made,  is  an  infusion.  There  are  two 
official  infusions: 

Infusion  of  Digitalis  (Infusum  Digitalis). 

Compound  Infusion  of  Senna,  Black  Draught  (Infusum  Senn«  Com- 

positum) . 

3.  Decoctions. — Decocta. — Decoctions  are  liquid  preparations 
made  by  pouring  boiHng  water  on  vegetable  drugs  in  a  suitable 
vessel  provided  with  a  cover,  allowing  it  to  boil  for  fifteen  minutes, 
and  then,  when  sufficiently  cooled,  strain.  Coffee,  as  usually  made, 
is  a  decoction.     There  are  no  official  decoctions. 

4.  Vinegars. — Aceta. — Vinegars  are  liquid  preparations  made  by 
treating  vegetable  drugs  with  dilute  acetic,  acid.  They  are  not 
much  used  in  dentistry.     Only  one  is  official: 

Vinegar  of  SquiUs  (Acetum  Scillae). 

5.  Tinctures. — Tinctura. — These  are  alcoholic  or  hydroalcohoKc 
solutions  of  the  soluble  constituents  of  crude  drugs  or  of  non-volatile 
substances  (except  iodin).  Tinctures  are  the  simplest  form  of  alco- 
hoHc  products  by  extraction,  and  as  a  class  have  no  uniform  strength. 
Tinctures  of  potent  drugs  are  made  of  the  strength  of  ten  grammes 
of  drug  in  one  hundred  mils  of  tincture.  The  other  tinctures 
vary  in  the  proportion  of  drug  in  the  finished  product.  Where  it 
has  been  found  possible  and  desirable  to  standardize  the  tinctures, 
an  assay  is  required  by  the  U.S. P.  This  is  true  of  tincture  of 
opium,  tincture  of  deodorized  opium,  and  tincture  of  nux  vomica. 
From  a  tincture  all  the  other  preparations  may  be  progressively  pro- 
duced through  concentration  by  evaporating  the  menstruum,  as 
follows: 

Fluid  extract  representing  a  uniform  drug-strength,  viz.:  i  troy 
ounce  in  i  fluidounce  (i  gram  in  i  mil). 

Extract,  or  "solid  extract,"  a  semi-solid  mass  of  pilular  consistence 


14  PHARMACEUTIC   PEEPARATIONS 

of  no  uniform  drug  strength,  or  assayed  and  powdered  with  diluent, 
to  represent  a  certain  alkaloidal  strength  (opium  and  nux  vomica). 

Abstract,  or  "powdered  extract,"  by  incorporating  sugar  of 
milk  with  the  extract  to  represent  one-half  the  weight,  or  twice  the 
strength  of  the  drug. 

Resins,  separation  of  the  resinous  constituents,  by  precipitation 
in  water  of  a  concentrated  alcoholic  tincture. 

Tinctures  are  applied  locally  or  administered  internally  by  den- 
tists more  than  any  other  subclass  of  pharmaceutic  preparations. 
The  following  tinctures  are  among  the  most  important: 

Tincture  of  Aconite  (Tinctura  Aconiti). 
Tincture    of    Belladonna    Leaves     (Tinctura    Belladonnas 
Folicrum). 

Tinctura  Benzoin  (Tinctura  Benzoini). 

Compound  Tincture  of  Benzoin  (Tinctura  Benzoini  Com- 
posita). 

Tincture  of  Cannabis  (Tinctura  Cannabis). 
Tincture  of  Cantharides  (Tinctura  Cantharidis). 
Tincture  of  Capsicum  (Tinctura  Capsici). 
Tincture  of  Calendula  (Tinctura  Calendulae)  (Nonofficial). 
Tincture  of  Cinchona  (Tinctura  Cinchonae). 
Compound    Tincture    of    Cinchona,    Huxham's    Tincture 
(Tinctura  Cinchonae  Composita).    , 
Tincture  of  Cinnamon  (Tinctura  Cinnamomi). 
Tincture  of  Digitalis  (Tinctura  Digitalis). 
'    Tincture  of  Ferric  Chlorid  (Tinctura  Ferri  Chloridi). 
Tincture  of  Gelsemium  (Tinctura  Gelsemii). 
Compound  Tincture  of  Gentian  (Tinctura  Gentianae  Com- 
posita). 

Tincture  of  Hyoscyamus  (Tinctura  Hyoscyami). 
Tincture  of  Hydrastis,  Tincture  of  Golden  Seal   (Tinctura 
Hydrastis) . 

Tincture  of  lodin  (Tinctura  lodi). 
Tincture  of  Kino  (Tinctura  Kino), 
Tincture  of  Myrrh  (Tinctura  Myrrhae). 
Tincture  of  Nux  Vomica  (Tinctura  Nucis  Vomicae). 
Tincture  of  Opium,  Laudanum  (Tinctura  Opii). 
Camphorated  Tincture  of  Opium,  Paregoric  (Tinctura  Opii 
Camphorata). 

Tincture  of  Deodorized  Opium  (Tinctura  Opii  Deodorati). 
Tincture  of  Rhubarb  (Tinctura  Rhei). 

Ammoniated  Tincture  of  Valerian  (Tinctura  Valerianae  Am- 
moniata). 

6.  Fluid  Extracts. — Fluidextracta.-^These  are  concentrated  tinc- 
tures of  such  strength  as  to  closely  represent  the  drug  volume  for 


PHARMACEUTIC   PREPARATIONS  1 5 

weight,  i.e.,  one  fluidounce  must  represent  the  active  principles  of 
one  troy  ounce  of  the  air-dried  and  powdered  drug  of  standard  quality 
( I  mil  =  I  gram) . 

The  preparations  in  this  class  are  prescribed  largely  by  physi- 
cians, for  they  possess  the  advantage  of  having  a  uniform  strength. 
They  are  not  employed  by  dentists,  however,  as  much  as  are  the 
tinctures.     The  most  important  fluid  extracts  are: 

Fluid  Extract  of  Aconite  (Fluidextractum  Aconiti). 
Aromatic  Fluid  Extract  (Fluidextractum  Aromaticum). 
Fluid  Extract  of  Belladonna  Root  (Fluidextractum  BeUa- 
donnae  Radicis). 

Fluid  Extract  of  Cannabis  (Fluidextractum  Cannabis). 
Aromatic  Fluid  Extract  of  Cascara  Sagrada  (Fluidextractum 
CascarcC  Sagradse  Aromaticum). 

Fluid  Extract  of  Cinchona  (Fluidextractum  Cinchonse). 
Fluid  Extract  of  Digitalis  (Fluidextractum  Digitalis). 
Fluid  Extract  of  Ergot  (Fluidextractum  Ergotae). 
Fluid  Extract  of  Eucalyptus  (Fluidextractum  Eucalypti). 
Fluid  Extract  of  Gelsemium  (Fluidextractum  Gelsemii). 
Fluid  Extract  of  Gentian  (Fluidextractum  Gentianae). 
Fluid  Extract  of  Hydrastis  (Fluidextractum  Hydrastis). 
Fluid  Extract  of  Hyoscyamus  (Fluidextractum  Hyoscyami).    . 
Fluid  Extract  of  Ipecac  (Fluidextractum  Ipecacuanhas). 
Fluid  Extract  of  Nux  Vomica  (Fluidextractum  Nucis  Vomicae). 
Fluid  Extract  of  Senna  (Fluidextractum  Sennae). 

7.  Extracts. — Extracta. — These  are  soluble  active  principles  of 
vegetable  drugs  concentrated  by  evaporation  to  a  soft  solid.  They 
are  called  "solid"  or  "pilular"  extracts  to  distinguish  them  from  fluid 
extracts.  They  preserve  the  useful  constituents  of  the  drug  in  a 
concentrated,  relatively  uniform  and  permanent  condition,  and  in  a 
form  suitable  for  medication.  When  employed,  they  are  usually 
dispensed  in  pills  or  capsules.  The  extract  of  opium  and  extract  oj 
nux  vomica  are  required  to  be  assayed,  as  are  other  extracts  of  potent 
drugs  where  it  has  been  found  possible  and  desirable  to  standardize 
them .     The  important  extracts  are : 

Extract  of  Aloes  (Extractum  Aloes). 

Extract  of  Cinchona  (Extractum  Cinchonae). 

Extract  of  Ergot  (Extractum  Ergotae). 

Extract  of  Hyoscyamus  (Extractum  Hyoscyami). 

Extract  of  Nux  Vomica  (Extractum  Nucis  Vomicae). 

Extract  of  Opium  (Extractum  Opii). 

Abstracts. — Abstracta. — These  are  a  class  of  powdered  extracts, 
formerly  recognized  by  the  U.S. P.   (1880),  prepared  from  the  ex- 


1 6  PHARMACEUTIC   PREPARATIONS 

tracts  by  the  addition  of  sufficient  sugar  of  milk  to  make  the  product 
represent  one-half  its  weight  of  the  crude  drug.  The  abstracts  have 
a  uniform  relation  to  the  drug  in  that  one  grain  represents  two  grains 
of  the  drug,  just  as  the  fluid  extracts  have  the  uniform  relation  of 
representing  the  drug  volume  for  weight.  There  are  no  official 
abstracts.  An  ideal  abstract  can  be  made  from  tincture  of  valerian, 
as  the  volatile  oil  in  valerian  does  not  permit  of  the  evaporation 
necessary  for  an  extract.  Abstract  of  valerian  is  one  of  the  most 
practical  preparations  of  the  drug. 

8.  Oleoresins. — Oleoresinae. — There  are  natural  and  pharma- 
ceutic oleoresins.  The  natural  oleoresins  have  been  elsewhere 
considered.  The  pharmaceutic  oleoresins  are  semi-liquid  extracts, 
obtained  by  exhausting  oleoresinous  drugs  with  ether.  The  ether 
extracts  ^::cg(/  and  volatile  oils  from  drugs,  as  well  as  resins.  Oleo- 
resins are  not  used  in  dentistry  to  any  extent,  but  have  been  briefly 
considered  here  in  order  to  make  our  classification  complete.  An  ex- 
ample of  an  official  oleoresin  is : 

Oleoresin  of  Capsicum  (Oleoresina  Capsici). 

9.  Resins. — Resinae. — Resins  have  previously  been  considered 
under  the  constituents  of  drugs.  The  official  resins  may  be  divided 
into  the  (i)  natural  resins,  (2)  resins  obtained  from  oleoresins  by 
separating  the  volatile  oil  by  distillation,  and  (3)  pharmaceutic 
resins,  prepared  by  precipitation.     An  example  of  an  official  resin  is: 

Resin  of  Podophyllum,  May  Apple  (Resina  Podophylli). 

IV.  MIXTURES  OF  SOLIDS 

The  general  class  called  mixtures  of  solids  includes  several  sub- 
classes of  pharmaceutic  preparations  for  internal  use: 

1.  Powders. — ^Pulveres. — These  are  impalpable  mixtures  of  one 
or  more  active  drugs,  usually  with  some  nearly  inert  substance, 
as  sugar  and  aromatics.  The  nearly  inert  substance  used  to  give 
bulk  to  official  powders  is  called  the  diluent.  The  important  powders 
are: 

Compound    Acetanilid    Powder    (Pulvis    Acetanilidi    Com- 

positus)  (Nonofficial). 

Compound  Chalk  Powder  (Pulvis  Cretse  Compositus). 

Compound  Effervescing  Powder,   Seidlitz  Powder   (Pulvis 

Effervescens  Compositus). 

Powder  of  Ipecac  and  Opium,   Dover's  Powder   (Pulvis 

Ipecacuanhae  et  Opii). 

Compound   Powder  of  Morphin,   TuUy's  Powder   (Pulvis 

Morphinae  Compositus). 


PHARMACEUTIC   PREPARATIONS  1 7 

2.  Effervescent  Salts. — Sales  Effervescentes. — These  are  granu- 
lated mixtures  of  salts  with  sugar,  sodium  bicarbonate  and  organic 
acids  (tartaric  and  citric) ,  which  effervesce  when  the  mixture  is  added 
to  water  and  furnish  agreeable  aerated  draughts.  They  were  new 
additions  to  the  U.S.  P.  VIII,  but  as  a  class  are  dropped  in  the  U.S. P. 
IX.  They  are  highly  useful  in  dentistry,  and  the  following  examples 
are  here  given: 

Effervescent  Cafifein  Citrate  (Caffeina  Citrata  Effervescens). 
Effervescent  Lithium  Citrate  (Lithii  Citrata  Effervescens). 
Effervescent  Magnesium  Sulphate  (Magnesii  Sulphas  Effer- 
vescens). 

Effervescent    Potassium    Citrate    (Potassii    Citrata    Effer- 
vescens). 

Effervescent    Sodium    Phosphate    (Sodii    Phosphas    Effer- 
vescens). 

3.  Confections. — Confectiones. — These  are  flavored  masses 
wherein  the  adhesive  substance  is  sugar  and  water,  or  honey,  serving 
as  a  vehicle  to  mask  the  taste  of  the  drug.  None  are  official  in  the 
U.S.P.  IX.     Examples  are: 

Confection  of  Rose  (Confectio  Rosae). 
Confection  of  Senna  (Confectio  Sennae). 

4.  Troches  or  Lozenges. — ^Trochisci. — These  are  confections 
made  in  various  forms  and  dried.  Most  of  the  troches  are  intended 
to  influence  the  mucous  membrane  of  the  mouth  and  throat,  and  are 
useful  preparations.     The  most  important  are: 

Troches  of  Tannic  Acid  (Trochisci  Acidi  Tannici). 
Troches  of  Ammonium  Chlorid  (Trochisci  Ammonii  Chloridi). 
Troches  of  Potassium  Chlorate  (Trochisci  Potassii  Chloratis). 
Troches  of  Sodium  Bicarbonate  (Trochisci  Sodii  Bicarbonatis). 

5.  Masses. — ^Massae. — These  are  plastic  mixtures  preserved  in 
bulk  and  intended  for  forming  into  pills.     There  are  two  offlcial: 

Mass  of  Ferrous  Carbonate,  Vallet's  Mass  (Massa  Ferri 

Carbonatis). 

Mass  of  Mercury,  Blue  Mass  (Massa  Hydrargyri). 

6.  Pills. — ^Pilulae. — These  are  spherical,  more  or  less  soluble 
masses  of  medicinal  substances  rendered  cohesive,  plastic,  and  firm 
in  consistence  by  the  addition  of  some  substance  (usually  inert), 
called  excipient.  The  kind  of  excipient  used  varies  with  the  nature 
of  the  medicinal  substance.  The  various  excipients  employed  are 
water,  alcohol,  glycerin,  syrups,  glucose,  glycerite  of  starch,  mucilage 
of  tragacanth,  etc. 


1 8  PHARMACEUTIC   PREPARATIONS 

The  following  pills  are  important : 

Pills  of  Aloes  (Pilulse  Aloes). 

Compound  Cathartic  PiUs  (Pilulag  Catharticae  Compositae). 

PiUs   of   Ferrous    Carbonate,    Blaud's   PiUs    (Pilulse   Ferri 

Carbonatis). 

Pills  of  Phosphorus  (Pilulae  Phosphori). 

7.  Tablets. — ^Tabellse. — These  are  small  disks  containing  med- 
icinal substances  mixed  with  sugar  and  mucilage.  They  are  a  con- 
venient form  in  which  to  administer  potent  remedies,  such  as  the 
alkaloids,  calomel,  etc.  Blank  tablets,  i.e.,  those  containing  no 
medicinal  substance,  can  be  obtained  and  serve  as  a  pleasant  means 
of  administering  concentrated  liquid  preparations,  such  as  the  fluid 
extracts,  by  dropping  from  two  to  five  minims  of  the  preparation  on 
the  tablet.  The  U.S. P.  IX  recognized  only  one  tablet;  and  this 
is  not  for  internal  use.     It  is  here  given : 

Poison  Tablets  of  Corrosive  Mercuric  Chlorid, 
Corrosive  Sublimate  Tablets,  Bichlorid  Tablets 
(Toxitabellae  Hydrargyri  Chloridi  Corrosivi). 

These  tablets  are  of  an  angular  shape  (not  discoid),  each  having 
the  word  "POISON"  and  the  skull  and  cross  bones  design  dis- 
tinctly stamped  upon  it.  The  tablets  are  to  be  colored  blue,  and 
each  must  contain  a  specified  amount  of  corrosive  mercuric  chlorid. 

V.  PREPARATIONS  FOR  EXTERNAL  USE 

This  class  of  pharmaceutic  preparations  includes  such  products 
as  are  used  for  external  medication.  Liniments,  oleates,  and  collo- 
dions are  employed  externally,  but  being  true  solutions  are  classified 
as  such.  The  classification  of  the  groups  here  considered  is  based 
upon  the  fusibility,  or  melting-point,  of  the  preparations,  which  is 
governed  by  the  respective  vehicles  employed. 

1.  Ointments. — ^Unguenta. — These  are  mixtures  wherein  med- 
icinal substances  are  incorporated  in  a  fatty  vehicle.  The  vehicles 
used  are:  Benzolated  lard,  lard  and  wax  or  spermaceti  in  varying' 
proportions,  lard  oil,  olive  oil  and  suet.  Petrolatum  and  lanolin 
(wool-fat)  are  largely  used  in  nonofiicial  ointments.  The  following 
are  important  official  ointments: 

Ointment  of  Boric  Acid  (Unguentum  Acidi  Borici). 
Ointment  of  Tannic  Acid  (Unguentum  Acidi  Tannici). 
Ointment  of  Rose  Water,  Cold  Cream  (Unguentum  Aquae   . 
Rosae). 


PHARMACEUTIC   PREPARATIONS  1 9 

Mercurial  Ointment  (Unguentum  Hydrargyri). 

Diluted  Mercurial  Ointment,  Blue  Ointment  (Unguentum 

Hydrargyri  Dilutum). 

lodin  Ointment  (Unguentum  lodi). 

Iodoform  Ointment  (Unguentum  lodoformi). 

Ointment  of  Phenol,  Ointment  of  Carbolic  Acid  (Unguentum 

Phenolis) . 

Ointment  of  Zinc  Oxid  (Unguentum  Zinci  Oxidi). 

Nonofficial  ointments  in  use  are: 

Ointment  of  Arsenic  Trioxid,  Devitalizing  Paste  (Unguentum 

Arseni  Trioxidi). 

Ointment  of  Camphor  (Unguentum  Camphorse,  N.F.). 

Ointment   of   Europhen   and  Orthoform,  Euroform   Paste 

(Unguentum  Europheni  et  Orthoformi). 

Ointment  of  Paraformaldehyd  and  Neothesin,  Desensitizing 

Paste  (Unguentum  Paraformaldehydi  et  Neothesini). 

2.  Cerates. — Cereata. — These  are  mixtures  of  medicated  fats 
similar  to  ointments,  but  of  firmer  consistence  because  they  contain 
wax,  resin,  or  paraffin,  which  raises  the  melting-point.  The  im- 
portant official  cereates  are: 

Simple  Cereate  (Cereatum). 

Cantharides   Cereate,   Blistering   Cereate    (Cereatum   Can- 

tharidis). 

Important  nonofficial  cereates  are : 

Compound   Cereate  of   Camphor,   Camphor  Ice   (Cereatum 
Camphorae  Compositum,  N.F.). 

Cereate  of  Bismuth  Subnitrate,  Beck's  Cereate  (Cereatum 
Bismuthi  Subnitras). 

3.  Suppositories. — Suppositoria. — These  are  variously  shaped 
masses  of  medicated  fats,  intended  to  be  inserted  into  the  orifices  of 
the  body,  as  the  rectum,  vagina,  urethra,  or  nostril.  The  usual 
vehicle  is  oil  of  theobroma  (cacao  butter).  Suppositories  are 
expected  to  melt  at  body  temperature.     The  only  ofiicial  one  is: 

Suppositories  of  Glycerin  (Suppositoria  Glycerini). 

4.  Plasters. — ^Emplastra. — Mixtures  of  soHds  having  a  fatty  or 
resinous  vehicle,  and  of  such  high  melting-point  as  to  be  friable  when 
cold,  but  rendered  adhesive  by  the  warmth  of  the  body. 

The  vehicles  of  plasters  are:  Lead  plaster;  resinous  substances, 
made  adhesive  by  admixture  with  the  medicinal  ingredients,  and 
simple  plasters,  such  as  isinglass.     Important  official  plasters  are: 

Belladonna  Plaster  (Emplastrum  Belladonnae). 
Capsicum  Plaster  (Emplastrum  Capsici). 


20  PHARMACEUTIC   PREPARATIONS 

Rubber  Plaster,  Rubber  Adhesive  Plaster  (Emplastrum 

Elasticum). 

Mustard  Piaster,  Mustard  Paper  (Emplastrum  Sinapis). 

A  nonofficial  plaster  is : 

Isinglass  Plaster,  Court  Plaster  (Emplastrum  Ichthyocollse). 

5.  Papers. — Chartas. — These  are  strips  of  unsized,  white  paper 
saturated  or  coated  with  some  medicinal  substance.  They  are 
intended  to  be  moistened  and  apphed  as  a  plaster,  or  else  to  be 
burned  and  the  fumes  inhaled.  The  only  one  official  in  the  U.S. P. 
Vin  was  Mustard  Paper  (Charta  Sinapis) .  This  is  now  recognized 
as  a  plaster  proper,  as  mentioned  above. 

6.  Poultices. — Cataplasmata. — These  are  semi-Hquid  prepara- 
tions made  by  mixing  such  coarsely  ground  substances  as  flaxseed, 
elm-bark,  or  bread,  with  hot  water  or  milk.  They  are  spread  upon 
cloth  or  poured  into  porous  bags,  and  used  for  appl3dng  heat  and 
moisture  to  the  tissues,  or  for  securing  a  local  stimulant  effect. 
Charcoal  is  sometimes  added  as  an  absorbent  and  mustard  as  a 
stimulant.  There  are  none  official.  The  U.S.P.  VIII  recognized 
the  following: 

Cataplasm  of  Kaolin  (Cataplasma  Kaolini). 

7.  Fomentations. — ^Fomenti. — These  are  porous  woolen  cloths 
saturated  with  hot  infusion  or  decoction  of  herbs,  or  other  hot 
Hquids  or  lotions  (saturated  solution  of  boric  acid) ,  and  appUed  hot. 
They  are  useful  preparations,  but  none  official. 

8.  Absorbent  Cotton. — Gossypium  Purificatum. — The  hairs  of 
the  seed  of  cotton,  freed  from  oil  and  resinous  substances  by  treat- 
ment with  alkalies  and  bleaching  agents.  These  hairs  represent 
microscopic  ducts  through  which  Uquids  are  absorbed  by  capiUary 
attraction.  The  absorbabihty  of  cotton,  then,  depends  upon  its 
purity,  or  the  freedom  from  oily  and  resinous  substances.  This  is 
equally  true  of  all  other  material  used  for  bandages. 

MISCELLANEOUS   LIST  OF  NONOFFICIAL  BANDAGES,  SPLINTS, 

MEDICATED  AND  ANTISEPTIC  DRESSINGS,  AND 

MEDICATED  GAUZES 

Bandages. — These  are  mechanical  supports,  serving  also  to 
keep  wounds  clean  by  absorbing  and  withdrawing  such  secretions 
as  would  otherwise  prove  irritating,  and  by  protecting  the  wound 
from  extraneous  matter,  thus  promoting  the  process  of  healing. 


METHODS   OF  ADMINISTERING   OR  APPLYING  DRUGS  21 

Plaster-of-Paris  Bandages. — These  are  made  by  thoroughly 
incorporating  a  good  quality  of  plaster-of-Paris  (calcium  sulphate) 
into  linen  bandages.  After  the  bandage  is  adjusted,  water  is  applied, 
when  it  sets  in  a  few  minutes. 

Splints. — These  are  mechanical  supports  made  from  wood, 
metals  (gold,  platinum,  lead,  German  silver,  etc.),  and  vulcanite 
rubber.  They  serve  the  purpose  of  holding  in  proper  position  or 
aHgnment  fractured  bones  and  loosened  teeth.  The  metallic  splints 
are  especially  useful  in  orthodontia,  pyorrheal  treatment  and  the 
reduction  of  fractures  of  the  mandible. 

Medicated  and  Antiseptic  Dressings. — These  are  made  by  satu- 
rating such  materials  as  cotton,  silk,  wool,  or  asbestos  fiber  in  a 
certain  strength  solution  of  the  medicinal  agent,  or  by  incorporating 
the  latter  in  powdered  form.  The  fabric,  which  conveys  the  agent, 
simply  serves  as  a  vehicle  for  the  medicinal  or  antiseptic  drug.  This 
means  is  largely  employed  in  the  application  of  medicines  to  the 
canals  of  teeth. 

Medicated  Gauzes. — The  material  used  in  making  medicated 
gauzes  is  pure  muslin  gauze,  which  is  thoroughly  saturated  with 
a  certain  strength  solution  of  the  medicinal  substance  desired,  then 
forcibly  expressed,  after  which  it  is  ready  for  use.  Medicated 
gauzes  should  be  kept  in  tightly  covered  boxes  or  jars  in  a  cool,  dry 
place.  They  are  largely  used  for  packing  and  medicating  wounds. 
The  following  gauzes  are  in  common  use: 

B  orated  Gauze.  Iodoform  Gauze. 

Phenolized  Gauze.  Euroform  Gauze. 

METHODS  OF  ADMINISTERING  OR  APPLYING  DRUGS 

The  physiologic  and  therapeutic  effect  of  remedies  is  often  largely 
determined  by  the  methods  in  which  they  are  administered  or  ap- 
plied ;  and  it  is  a  well-estabHshed  principle  that  the  nearer  the  remedy 
is  appUed  to  the  site  of  the  disease  the  more  effectual  and  safer  is 
its  use.  Recognizing  this  principle,  remedies  should  be  appHed 
locally  as  far  as  possible.  There  are  many  pathologic  conditions, 
however,  confronting  the  dentist  which  cannot  be  reached  and  acted 
upon  favorably  by  the  local  appHcation  of  medicines.  It  is,  there- 
fore, the  plain  duty  of  every  practitioner  of  dentistry  to  so  familiar- 
ize himself  with  drugs  and  their  internal  administration  that  he  will 
be  able  to  treat  successfully  any  case  which  arises  in  his  practice. 

By  the  Mouth. — This  is  the  original  and  most  common  method 
employed  for  the  administration  of  the  great  majority  of  medicines. 


22  METHODS    OF   ADMINISTERING   OR   APPLYING   DRUGS 

Drugs  are  given  by  the  mouth  for  their  local  action  on  the  mucous 
membrane  and  deeper  seated  tissues  of  the  mouth,  throat,  stomach, 
or  intestines,  or  for  the  purpose  of  being  absorbed.  The  absorp- 
tion of  drugs  may  take  place  from  any  part  of  the  alimentary  canal. 
Some  powerful  remedies  are  readily  absorbed  from  the  tongue. 
A  dose  of  spirit  of  nitroglycerin,  placed  under  the  tongue,  will  pro- 
duce its  physiologic  effect  in  from  three  to  five  minutes.  Remedies 
intended  to  influence  the  mouth  or  throat  are  often  given  in  the  form 
of  a  troche  or  lozenge.  When  absorption  of  the  remedy  from  the 
stomach  is  desired,  it  should  be  administered  in  solution  or  in  such 
condition  as  to  be  acted  upon  by  the  gastric  secretions  and  made 
soluble.  The  reaction  of  the  gastric  juice  is  acid,  while  the  intestinal 
juices  are  alkaline.  Any  substance,  therefore,  soluble  in  either  an 
acid  or  alkaline  medium,  is  acted  upon  favorably  by  the  secretions 
of  the  stomach  or  intestines.  Such  remedies  as  calomel,  salol, 
and  salophen,  requiring  an  alkaline  liquid  for  their  solution,  pass 
through  the  stomach  practically  unchanged,  and  are  digested  and 
absorbed  almost  entirely  in  the  intestines.  The  general  rule  for 
administering  remedies  intended  to  be  absorbed  in  the  stomach  is 
to  give  them  on  an  empty  stomach,  that  is,  half  an  hour  or  an  hour 
before  meals.  This  rule  should  not  be  followed,  however,  in  the 
case  of  remedies  having  a  local  irritant  action,  as  potassium  bromid 
or  potassium  iodid,  etc.  It  is  far  better  to  give  these  remedies 
well  diluted  in  water,  and  immediately  after  meals,  so  that  their 
local  effect  is  more  or  less  avoided  by  their  admixture  with  the 
food. 

Hj^odermic. — This  method  consists  in  injecting  solutions  of 
medicinal  substances  into  the  submucous  and  subcutaneous  tissues 
by  means  of  the  hypodermic  needle  and  syringe,  and  is  largely 
employed  in  dental  practice.  The  method  has  many  advantages, 
such  as  the  great  rapidity  with  which  absorption  is  effected,  for  local 
medication,  and  the  certainty  of  securing  the  action  of  the  entire 
dose.  The  alkaloidal  salts,  as  cocain  hydrochlorid,  on  account  of 
their  small  bulk,  are  especially  adapted  for  hypodermic  use.  The 
dose  of  a  drug  given  hypodermically  is  generally  about  one-half 
that  given  by  the  mouth  or  stomach.  There  are  several  conditions 
wherein  the  hypodermic  method  of  administering  drugs  is  strongly 
indicated,  viz. : 

1 .  In  conditions  where  the  patient  is  unable  to  swallow,  or  where 
the  stomach  is  unable  to  receive  or  retain  medicines. 

2.  In  conditions  necessitating  the  immediate  action  of  a  drug  or 
remedy,  or  where  absolute  certainty  of  the  dose  is  desired. 


METHODS    OF   ADMINISTERING   OR   APPLYING   DRUGS  23 

3.  In  conditions  where  local  medication  is  desired  for  the  pro- 
duction of  local  anesthesia,  for  the  relief  of  pain,  as  in  neuralgia,  or 
for  stimulation  of  a  deep-seated  part. 

The  first  two  indications  mentioned  for  this  method  of  administer- 
ing drugs  are  of  interest  to  dentists  in  that  the  method  is  employed 
here  in  cases  of  emergency,  as  in  collapse.  The  third  indication  is  of 
prime  importance,  as  it  is  employed  every  day  in  a  busy  practice 
for  the  purpose  of  injecting  local  anesthetics  and  other  drugs  for 
the  mitigation  of  pain. 

The  factors  to  be  remembered  in  using  this  method  are: 

1.  Guard  against  septic  infection. 

2.  Prevent  the  injection  of  air  into  a  vein. 

3.  Prevent  the  injection  of  the  medicine  into  a  vein,  unless  in 
cases  of  emergency. 

To  guard  against  septic  infection,  it  is  necessary  to  have  the 
hands  and  the  field  of  operation  as  nearly  sterile  as  they  can  be 
made  and  to  have  the  h3^odermic  syringe,  needle,  and  the  solution 
absolutely  sterile. 

To  prevent  injecting  air  into  a  vein,  it  is  essential  that  all  of  the 
air  should  be  exhausted  from  the  syringe  before  the  injection  is 
made.  When  the  syringe  is  filled  by  drawing  the  solution  into  it, 
hold  the  point  upward,  tapping  the  side  of  the  syringe  gently  to 
dislodge  any  air  bubbles,  then  by  pushing  the  piston  until  the  solu- 
tion escapes,  the  air  is  expelled.  There  is  little  danger  of  injecting 
air  into  a  vein  when  the  solution  is  injected  into  the  submucous 
tissue  of  the  mouth;  nevertheless,  it  is  well  to  avoid  injecting  air 
into  the  tissues,  and  when  this  method  of  drug  administration  is 
used  other  than  in  the  mouth,  the  danger  is  correspondingly  in- 
creased. If  air  enters  a  vein  it  is  carried  directly  to  the  right  side 
of  the  heart,  where  by  the  action  of  the  tricuspid  valve  it  forms  a 
foam  with  the  blood,  resulting  in  air-thrombosis,  which  might  cause 
death. 

Occasionally  in  an  emergency  it  is  desired  to  inject  the  medicine 
into  a  vein  that  it  may  be  at  once  carried  to  the  heart;  but  ordinarily 
this  should  be  avoided.  To  unintentionally  inject  the  entire  quantity 
into  a  vein  might  result  in  an  overdose.  By  injecting  slowly  and 
holding  the  finger  over  the  needle-point,  one  can  readily  guard  against 
this  danger.  If  the  fluid  accumulates,  which  should  be  easily  de- 
tected by  the  finger,  nothing  need  be  feared;  but  if  the  fluid  escapes 
readily  and  the  accumulation  cannot  be  detected,  one  may  suspect 
that  a  vein  has  been  punctured.  In  this  case  the  needle  should  be 
slightly  withdrawn  and  the  injection  continued. 


24  METHODS    OF   ADMINISTERING    OR   APPLYING   DRUGS 

The  Hypodermic  Syringe. — There  are  many  varieties  of  hypo- 
dermic syringes  on  the  market.  It  was  difficult  to  thoroughly  steril- 
ize the  old-style  glass  barrel  and  leather-covered  piston  syringe. 
During  the  past  few  years  a  great  improvement  has  been  made  in 
both  the  glass  barrel  and  all-metal  syringes.  The  former  has  the 
advantage  of  permitting  a  view  of  the  fluid  or  air  within  the  barrel; 
the  latter  the  advantage,  if,  indeed,  it  is  an  advantage,  of  being 
sterilized  by  boiling.  It  is  no  doubt  true  that  the  repeated  boiling 
of  a  hypodermic  syringe  will  soon  cause  it  to  leak  and  unfit  it  for 
use.  It  has  also  been  found  the  safest  and  best  practice  to  keep  the 
syringes,  needles,  etc.,  when  not  in  use,  immersed  in  about  a  70 
per  cent,  solution  of  alcohol,  to  which  i  per  cent,  of  thymol  and 
about  5  per  cent,  of  glycerin  has  been  added.  This  may  be 
done  by  having  a  suitable  glass  jar  for  the  purpose.  There  are  a 
variety  of  syringes  and  needles  on  the  market.  The  operator  should 
select  and  keep  on  hand  the  kinds  which  best  meet  his  daily  need. 

Technic  of  the  Injection. — The  method  of  injecting  medicines 
hypodermically  differs  somewhat  with  the  site  of  application;  there- 
fore, it  will  be  discussed  under  different  headings: 

1.  Through  the  skin  into  the  cellular  tissue  of  the  body. 

2.  Through  the  mucous  membrane  into  the  various  submucous 
tissues,  such  as  the  gums,  gingivae  and  alveolar  process. 

3.  Through  the  tooth  structure  into  the  pulp  tissue. 

•  In  injecting  drugs  hypodermically  through  the  skin  it  is  essential 
to  guard  against  the  dangers  incident  to  this  method  of  administering 
medicine.  The  solution  should  be  sterile  to  begin  with,  the  syringe 
and  needle  may  be  sterilized  as  the  operator  deems  best,  the  hands 
by  washing  with  green  soap  and  followed  with  an  application  of  alco- 
hol (60  to  70  per  cent.),  1-1,000  solution  of  mercuric  chlorid,  or  1-500 
solution  of  sublamin;  the  site  of  application  may  be  sterilized  in  the 
same  manner  as  the  hands.  Various  solutions  containing  iodin  are 
also  popular  for  this  purpose.  The  selection  of  the  site  for  making 
the  injection  depends  upon  the  circumstances  of  the  case.  It  may 
be  made  upon  any  accessible  part  of  the  body,  usually,  however,  the 
arm  or  lumbar  region  of  the  back.  After  exhausting  the  air  from  the 
syringe,  hold  it  firmly  in  the  right  hand,  and  with  the  left  grasp  the 
skin  at  the  selected  site.  The  needle  should  now  be  pushed  quickly 
through  the  skin  at  nearly  right  angles  to  the  surface,  and  should 
penetrate  quite  deeply.  The  injection  should  be  made  slowly,  and 
with  the  forefinger  of  the  left  hand  determine  whether  it  is  causing 
distention  of  tissue  or  escaping  rapidly. 

The  dentist,  as  has  been  intimated,  is  particularly  interested 


METHODS    OF   ADMINISTERING    OR   APPLYING   DRUGS  25 

in  the  technic  of  injecting  drugs  li3^odemiically  through  the  mucous 
membrane  and  into  the  various  submucous  tissues  (both  soft  and 
hard)  for  the  purpose  of  producing  local  anesthesia.  In  the  past 
there  seems  to  have  been  an  inherent  prejudice  by  many  practi- 
tioners against  the  use  of  local  anesthetics  in  dentistry.  The  author 
and  many  others  have  advocated  their  use  for  years.  Cocain  was 
the  drug  largely  used.  With  the  introduction  and  use  of  novocain, 
a  synthetic  substitute  for  cocain,  and  a  drug  claimed  to  be  far  less 
toxic,  this  prejudice  has  gradually  disappeared.  The  insistent 
demand  for  "painless  dentistry"  has  made  the  use  of  local  anesthetics 
and  the  h3rpodermic  method  of  administering  the  same  very  popular 
in  dental  practice. 

It  is  sufficient  at  this  time  for  the  student  to  learn  that  local 
anesthesia  in  the  mouth  is  produced  in  three  ways:  Infiltration, 
interosseous  and  conductive  (nerve  blocking)  anesthesia.  In  the 
infiltration  method  the  local  anesthetic  solution  is  injected  in  the 
submucous  tissues  immediately  around  the  part  to  be  anesthetized, 
simply  permitting  the  solution  to  infiltrate  the  tissues.  The  interos- 
seous method  consists  of  first  making  a  small  submucous  injection 
to  anesthetize  a  small  area  of  gum  tissue  when  the  latter  and  cortex 
of  the  bone  are  pierced  with  a  suitable  drill;  through  which  opening 
a  few  minims  of  the  solution  are  deposited  slowly,  permitting  it  to 
difuse  through  the  spongiosa  of  the  hone,  thus  producing  complete 
anesthesia  of  one  or  two  teeth  almost  instantly.  By  conductive 
anesthesia  or  nerve  blocking  is  meant  the  process  of  injecting  local 
anesthetic  solutions  submucously  into  the  tissues  surrounding  the 
foramen  through  which  the  nerve  makes  its  entrance  or  exit;  thus 
anesthetizing  the  nerve  at  this  point,  when  the  effect  of  which  is 
conducted  to  the  periphery,  blocking  the  nerve  as  it  were,  and  causing 
temporary  loss  of  sensation  in  the  part  supplied  by  this  nerve. 
Before  anesthetizing  any  part  or  undertaking  any  surgical  operation, 
the  mouth  should  be  rinsed,  or,  better,  sprayed  with  an  antiseptic 
solution.  The  solution,  syringe,  needle,  hands  of  the  operator,  and 
field  of  operation  should  be  sterilized  as  previously  mentioned.  We 
have  considered  here  the  principles  of  local  anesthesia  only;  the 
detailed  technic  of  making  the  various  injections  will  be  considered 
later  as  occasion  requires. 

The  forcing  of  local  anesthetic  agents  through  the  tooth  structure 
and  into  the  pulp  is  known  as  pressure  anesthesia  and  is  elsewhere 
considered. 

Epidermic  or  Inunction. — This  method  consists  in  applying 
medicinal  substances,  dissolved  in  fatty  vehicles,  to  the  unbroken 


26  METHODS    OF   ADMINISTERING   OR   APPLYING   DRUGS 

skin  when  absorption  of  the  remedy  is  fairly  well  brought  about,  espe- 
cially if  friction  be  used  in  their  application.  Ointments  are  largely 
employed  in  this  manner. 

Intravenous. — This  method  is  used  in  great  emergency  where 
it  is  desired  to  inject  a  stimulating  or  restorative  agent  directly  into  a 
vein.  Physiologic  salt  solution  (6  parts  of  sodium  chlorid  in  i,ooo 
parts  of  sterile  water — 6  grams  in  i,ooo  mils)  is  the  remedy  mostly 
employed  in  this  manner.  The  solution  is  intended  to  correspond  to 
blood  serum  in  salinity,  and  is  given  intravenously  in  cases  of  copious 
hemorrhage,  or  in  collapse. 

Cataphoresis. — This  method  consists  in  the  introduction  of 
drugs  in  molecular  form  into  tooth  structure  or  living  tissue  by  means 
of  the  electric  current.  The  positive-pole  applicator  is  saturated  with 
a  concentrated  solution  of  the  drug  and  placed  within  a  cavity  in  the 
tooth  being  treated,  or  directly  over  the  part  to  be  medicated,  the 
negative  pole  being  placed  somewhere  on  the  patient's  body, — usually 
held  in  the  hand  by  means  of  a  moist  sponge.  This  method,  with 
cocain  hydrochlorid  as  the  drug,  has  been  used  to  obtund  sensitive 
dentin  and  to  anesthetize  the  dental  pulp  for  the  purpose  of  its  pain- 
less removal.  The  method  will,  therefore,  again  be  considered  more 
in  detail. 

By  the  Rectum. — This  method  is  employed  for  the  administra- 
tion of  both  medicines  and  food,  whenever,  on  account  of  inability  to 
swallow  or  persistent  vomiting,  the  mouth  or  stomach  route  cannot 
be  used.  The  process  of  making  the  rectal  injection  is  known  as 
Enema.  Absorption  through  the  rectum  is  not  nearly  so  rapid 
as  through  the  stomach,  hence  to  accomplish  the  same  result  it 
generally  requires  twice  the  dose  by  the  rectum  that  would  be  neces- 
sary by  the  mouth,  and  solution  of  the  drug  should  be  assured  before 
it  is  administered,  unless  a  local  effect  is  intended.  For  local  medica- 
tion suppositories  are  largely  employed. 

Inhalation. — This  method  can  only  be  employed  for  volatile 
drugs  or  finely  atomized  liquids.  Volatile  drugs  are  rapidly  absorbed 
from  the  respiratory  tract,  and  this  method  is  largely  used  in  dental 
practice  for  the  administration  of  such  drugs  as  nitrous  oxid,  chloro- 
form, and  ether,  when  the  general  analgesic  or  general  anesthetic 
effect  is  desired.  The  stimulating  effect  of  such  drugs  as  ammonia 
and  amyl  nitrite  is  also  produced  by  inhalation.  When  it  is  desired 
to  influence  directly  the  mucous  membrane  of  the  mouth  and  respira- 
tory tract,  medicated  vapors  and  sprays  are  often  employed. 


CONDITIONS   MODIFYING   THE   ACTION   AND    EFFECT    OF   DRUGS       27 

CONDITIONS   MODIFYING   THE   ACTION  AND 
EFFECT  OF  DRUGS 

There  are  many  conditions  or  circumstances  which  influence  and 
modify  the  action  and  effect  of  drugs,  chief  of  which  are  the  age  of 
the  patient,  the  sex,  race,  size,  temperament,  disease,  temperature, 
habit  and  idiosyncrasy,  the  method,  time  of  administration,  prepa- 
ration, and  dose  of  the  drug. 

Habit. — The  tissues  of  the  body  can  be  induced  to  tolerate  many 
drugs  by  their  continuous  administration.  This  is  particularly  true  of 
opium  and  cocain.  It  is  not  definitely  known  just  how  this  condition 
is  brought  about,  but  it  is  beheved  to  be  largely  due  to  a  change  in 
the  tissues  themselves  whereby  they  are  rendered  less  susceptible  to 
the  influence  of  the  drug.  There  is  a  crying  demand  to-day  for  "pain- 
less dentistry,"  and  most  dental  operations  can  be  made  practically 
painless  by  the  judicious  use  of  narcotic  drugs,  especially  the  local 
anesthetics.  Therefore,  a  word  of  caution  here  regarding  the  danger 
of  forming  the  drug-habit  will  not  be  out  of  place.  This  habit  is  far 
more  common  than  is  generally  known.  It  is  the  duty  of  every 
dentist  to  employ  such  reasonable  measures  as  will  mitigate  pain, 
but  he  should  constantly  guard  his  patient,  as  well  as  himself,  against 
the  formation  of  the  drug-habit.  In  order  to  prevent  the  miscella- 
neous and  injudicious  prescribing  of  such  habit-forming  drugs  as 
opium  and  cocain.  Congress  in  191 5  passed  a  law,  known  as  the  "Harri- 
son Narcotic  Act,"  which  requires  physicians,  dentists,  and  veterinar- 
ians to  keep  a  record  of  all  drugs  used  which  are  included  in  the  Act. 

Idiosyncrasy. — This  is  a  pecuHar  susceptibihty  or  insusceptibility 
of  one  or  more  of  the  tissues  of  the  body  to  the  influence  of  certain 
drugs  for  which  no  explanation  can  be  found.  Less  than  3^  of  a  grain 
of  calomel  has  been  known  to  induce  salivation,  causing  an  inflam- 
mation in  the  pericemental  membrane  and  teeth  sore  to  pressure. 
With  some  individuals  the  smallest  dose  of  quinin  will  produce  a 
diffuse  erythematous  rash.  Many  patients  have  an  idiosyncrasy 
for  cocain,  the  smallest  amount  causing  all  of  the  toxic  symptoms 
characteristic  of  the  drug.  Other  patients  have  what  may  be  called 
a  presupposed  idiosyncrasy,  for  cases  are  on  record  where  the  patient 
had  all  the  S3niiptoms  of  cocain-poisoning  when  only  distilled  water 
had  been  hypodermically  injected,  the  patient,  however,  thinking 
cocain  had  been  used. 

One  form  of  idiosyncrasy  consists  in  the  failure  of  the  individual 
to  react  to  the  ordinary  dose  of  the  drug,  and  this  particular  form  is 
called  Tolerance. 


28    CONDITIONS   MODIFYING   THE   ACTION   AND    EFFECT    OF   DRUGS 

Cumulative  Effect. — This  is  another  phenomenon  of  drugs 
caused  by  their  prolonged  administration  when  sudden  and  often- 
times a  severe  effect  is  produced,  o^dng  to  the  "accumulation  of  the 
drug  in  the  tissues  of  the  body.  Cumulative  action  may  occur 
along  with  tolerance. 

Dosage  or  Posology. — Under  this  heading  can  be  discussed  most 
of  the  conditions  which  modify  the  effect  of  drugs  not  previously 
considered,  for  whatever  modifies  the  effect  of  drugs  must  also  neces- 
sarily influence  dosage.  In  regard  to  dosage  Butler^  says :  "  Common 
sense  ought  long  since  to  have  told  us  that  the  doses  prescribed  in 
text-books  are  only  based  upon  experience  in  certain  cases,  or  upon 
experimentation  made  upon  animals.  From  such  data,  however, 
the  first  author  who  wrote  upon  the  posology  of  different  substances 
started,  and  others  have  simply  copied  after  the  first.  If  any  fact 
went  beyond  the  well-defined  limits,  it  was  wont  to  be  explained 
by  the  defective  quality  or  method  of  preparation  of  the  drug,  or 
by  an  idiosyncrasy  so  rare  that  one  would  not  even  take  the  pains 
to  investigate  the  matter,  and  see  if  it  were  reaUy  less  rare  than  had 
been  beheved."  While  there  is  perhaps  a  maximum  and  a  minimum 
dose  for  the  various  drugs,  the  dose  of  a  remedy  should  be  governed 
largely  by  the  conditions  found  at  the  time  the  diagnosis  is  made  and 
the  medicine  prescribed,  taking  into  consideration  the  various 
circumstances  which  influence  the  action  and  effect  of  drugs.  The 
U.S.P.  IX,  recognizing  this  fact,  gives  only  the  "average  dose" 
for  an  adult.  Commenting  upon  this  the  U.S.P.  states:  "It  is 
to  be  distinctly  understood  that  neither  this  Convention  nor  the 
Committee  of  Revision  created  by  it  intends  to  have  these  doses 
regarded  as  obligatory  on  the  physician  or  as  forbidding  him  to 
exceed  them  whenever  in  his  judgment  this  seems  advisable."  Only 
the  average  dose  of  drugs  and  their  preparations  will  be  given  in  this 
book. 

The  age  of  a  patient  must  be  taken  into  account  in  the  internal 
administration  of  drugs.  Children  ought  to  receive  much  smaller 
doses  than  adults.  Young  calculates  the  dose  for  a  child  according 
to  the  following  formula:  Divide  the  age  by  the  age  +  12,  the  frac- 
tion obtained  is  taken  as  the  proportion  of  the  adult  dose  required. 
Thus,  for  a  child  four  years  old,  the  dose  would  be  (4  +  12  = )  ^i 
of  the  adult  dose;  for  a  child  twelve  years  old  (77-+ — ^  =)  /4  oi 
the  adult  dose. 

In  regard  to  the  sex,  women  require  somewhat  smaller  doses  than 
men.     During  pregnancy,  purgative  drugs,  or  preparations  of  ergot 

^  Text-book  of  Materia  Medica,  Therapeutics,  and  Pharmacology,  p.  46. 


CLASSIFICATION    OF   MEDICINES  29 

used  frequently  in  dental  practice  in  cases  of  hemorrhage  after  ex- 
traction, have  to  be  used  with  the  greatest  care,  because  purgatives 
induce  congestion  of  the  pelvis,  and  ergot  acts  directly  upon  the 
muscular  walls  of  the  uterus,  causing  contraction,  either  of  which 
conditions  may  lead  to  abortion.  Many  drugs  also  pass  from  the 
mother  to  the  child,  and  this  should  be  remembered,  as  quantities 
which  are  insujQ&cient  to  poison  the  former  may  have  serious  effects 
upon  the  latter.  During  lactation,  it  should  be  borne  in  mind  that 
many  active  drugs  may  be  excreted  in  the  milk,  and  may  either  act 
on  the  child  or  render  the  milk  distasteful  to  it. 

Pathologic  conditions  very  often  modify  the  effects  of  drugs  to 
a  considerable  extent,  and  in  a  way  which  pharmacologists  at  present 
cannot  explain.  As  an  example  of  this,  the  antipyretics  reduce  the 
temperature  in  fever,  but  have  no  effect  on  it  in  health;  bromids 
lessen  the  convulsions  in  epilepsy,  or  during  the  teeth-erupting 
period  in  children,  but  have  much  less  effect  in  depressing  the  brain 
in  normal  persons.  Strange  as  it  may  seem  to  the  student  or 
inexperienced  practitioner,  the  climate  or  temperature  has  a  con- 
trolling influence  on  the  action  and  effects  of  drugs,  as  well  as  on 
pathologic  conditions,  which  fact  has  been  demonstrated  by  clinical 
experience. 

The  method  and  time  of  administration  also  have  some  influence 
on  the  effects  of  drugs.  It  has  been  mentioned  elsewhere  that  the 
nearer  the  site  of  the  disease  the  remedy  is  applied  the  more  effectual 
and  safer  is  its  use.  It  is  also  true  that  the  body  is  generally  more 
resistant  in  the  morning  than  in  the  evening,  especially  in  the  case 
of  hypnotic  drugs;  thus  a  dose  of  chloral  hydrate,  for  example, 
which  may  have  httle  or  no  effect  in  the  morning  when  the  brain  is 
clear  and  active,  induces  sound  sleep  when  given  in  the  evening, 
because  the  brain  now  is  already  fatigued  and  depressed. 

CLASSIFICATION  OF  MEDICINES 

In  their  attempt  to  keep  pace  with  the  advancement  of  knowl- 
edge, writers  upon,  and  teachers  of.  Materia  Medica,  Pharmacology, 
and  Therapeutics  have  devised,  from  time  to  time,  various  systems 
of  classification  of  drugs  and  remedial  agents.  The  unsettled  state 
of  knowledge  regarding  normal  physiologic  processes  and  of  the 
physiologic  action  of  remedies  upon  pathologic  conditions  which 
they  are  expected  to  correct,  is  sufficient  reason,  in  the  author's 
opinion,  for  stating  that  therapeutics  is  far  from  being  an  exact 
science.  At  this  time,  therefore,  no  really  scientific  classification 
of  these  substances  is  possible.     It  is  imperative,  however,  as  an 


30  DEFESriTIOXS    OF   REMEDIES 

aid  to  the  student,  that  some  system  of  classification  be  followed, 
and,  inasmuch  as  the  tendency  in  modern  therapeutics  is  along 
rational  lines,  i.e.,  administering  or  applying  the  remedy  because  of 
its  known  pharmacologic  action,  a  system  of  classification  will  be 
followed  by  which  drugs  will  be  divided  into  local  and  general 
remedies,  and  grouped,  so  far  as  possible,  according  to  their  physio- 
logic action  and  therapeutic  application.  It  is  important,  however, 
that  the  student  familiarize  himself  at  the  beginning  of  the  study 
of  drugs  and  their  uses  with  the  definitions  of  remedies  with  reference 
to  their  action  upon  the  tissues,  organs,  and  functions  of  the  body. 
Therefore,  as  an  appropriate  introduction  to  that  part  of  this  work 
devoted  to  drugs  proper,  brief  definitions  of  remedies,  alphabetically 
arranged,  are  here  inserted,  together  with  practical  examples  of 
each. 

DEFINITIONS  OF  REMEDIES 

Antacids. — These  are  agents  which  neutralize  acids  by  reason 
of  their  alkaHne  or  basic  properties.     Examples  are : 

Sodium  Bicarbonate. 

Solution  of  Calcium  Hydroxid  (Lime-water). 

Magnesium  Hydroxid  (Milk  of  IMagnesia). 

Alteratives. — Agents  that  alter  or  counteract  morbid  condi- 
tions by  promoting  metabolism  or  the  processes  of  nutrition.  Exam- 
ples are: 

Potassium  lodid.  Arsenic. 

Mercury.  Cod-liver  Oil. 

Analgesics  or  Anod3aies. — These  are  agents  which  relieve  pain 
either  by  direct  depression  of  the  centers  of  perception  and  sensation 
in  the  cerebrum  or  by  impairing  the  conductivity  of  the  sensory 
nerve  fibers.     Examples  are: 

Opium.  The  Bromids. 

Butyl-chloral  Hydrate.  Aspirin. 

Anesthetics. — These  are  agents  which  temporarily  destroy 
sensation.  They  are  divided  into  two  classes,  local  and  general.  A 
local  anesthetic  aboHshes  sensation  in  a  part,  while  a  general  anes- 
thetic abolishes  all  sensation  and  induces  unconsciousness.  Exam- 
ples are: 

Local  anesthetics.  General  anesthetics. 

Cocain  Hydrochlorid.  Nitrous  Oxid. 

Eucain  Hydrochlorid.  Chloroform. 

Novocain  Hydrochlorid.  Ether. 

Ethyl  Chlorid  spray. 


DEFINITIONS    OF   REMEDIES  3 1 

Antagonists. — These  are  agents  which  directly  oppose  each 
other  in  some  or  all  of  their  pharmacologic  actions.  Advantage  is 
taken  of  drugs  which  antagonize  each  other  in  cases  of  poisoning. 
Important  examples  are: 

Strychnin  and  Cocain.  Atropin  and  Morphin. 

Caffein  and  Cocain. 

Anthelmintics. — These  are  agents  which  destroy  (vermicides) 
or  expel  (vermifuges)  intestinal  worms.     Examples  are: 

Pepo  (Pumpkin-seed).  Oil  of  Turpentine. 

Thymol. 

Antipyretics. — These  are  drugs  or  remedies  which  reduce  the 
body  temperature  when  abnormally  high.     Examples  are: 

Aconite.  The  Coal-tar  Products: 

Quinin.  Antipyrin.  Acetanilid. 

Phenacetin. 

Antiseptics. — These  are  agents  which  inhibit  the  growth  of 
microorganisms.     Examples  are: 

Oil  of  Cloves.  Benzoic  Acid. 

Phenol  (5  per  cent,  solution).     Sodium  Borate  (Borax). 
Boric  Acid.  Glycerin. 

Alcohol  (20  per  cent,  solution).  Betanaphthol. 

Antispasmodics.' — These  are  agents  which  control  spasms  and 
lessen  states  of  general  nervousness.     Examples  are: 

Camphor.       Compound  Spirit  of  Ethef  (Hoffmann's  Anodyne). 
Valerian. 

Astringents. — These  are  agents  which  contract  or  condense 
tissue.     Examples  are: 

Alum.  Zinc  Phenolsulphonate. 

Tannic  Acid.  Zinc  lodid. 

Bismuth  Subnitrate.  Silver  Nitrate. 

Zinc  Chlorid.  Copper  Sulphate. 

Bleachers. — These  are  agents  used  to  restore  the  color  of  tooth- 
structure.     Examples  are: 

Sodium  Dioxid.  Alphozone. 

Hydrogen  Dioxid.  Chlorin. 

Sulphurous  Acid. 

Carminatives. — These  are  agents  which  promote  the  expulsion 
of  gas  from  the  stomach.     Examples  are: 


32  DEFINITIONS    OF    REMEDIES 

Capsicum.  Pepper. 

Mustard.  Cinnamon. 

Ginger.  Cardamom. 

Cathartics. — These  are  agents  used  to  produce  evacuation  of  the 
bowels.  Cathartic  drugs  are  classified  according  to  the  intensity  of 
their  action.  Thus,  those  that  are  mild  in  action  and  produce  a 
nearly  normal  stool  are  called  laxatives.  Those  more  powerful,  usu- 
ally producing  more  copious  stools,  are  termed  purgatives.  Those 
which  produce  a  watery  evacuation  of  the  bowels  are  called 
hydragogues.  Those  which  gripe,  having  a  violent  action,  are  called 
drastics.     Examples  of  each  class  follow: 


Laxatives. 

Purgatives. 

Tamarind. 

Aloes. 

Cascara  Sagrada. 

Senna. 

Manna. 

Castor  Oil. 

Honey. 

Calomel. 

Figs. 

Rhubarb. 

Prunes. 

Blue  Mass. 

Hydragogues. 

Drastics. 

Magnesium  Sulphate. 

Croton  Oil. 

Sodium  Sulphate. 

Colocynth. 

Potassium  and 

Gamboge. 

Sodium  Tartrate  (Rochelle  Salt).  Jalap. 
Sodium  Phosphate.  Podophyllum. 

Magnesium  Citrate. 

Demulcents. — These  are  substances  largely  of  a  mucilaginous 
nature,  which  soothe  and  protect  the  parts  to  which  they  are  applied. 
Examples  are: 

Acacia.  MarshmaUow. 

Licorice.  Starch. 

Sassafras  Pith.  Flaxseed. 

Slippery  Elm.  White  of  Egg. 

Dentifrices. — These  are  medicated  powders  or  pastes  applied 
with  a  suitable  brush  to  cleanse  the  teeth  and  gums.  Precipitated 
chalk  (calcium  carbonate)  is  the  base  of  all  dentifrices.  For  ex- 
amples, see  Practical  Therapeutics,  p.  270. 

Deodorants. — These  are  agents  which  destroy  offensive  odors. 
Examples  are: 

Formaldehyd.  Potassium  Permanganate. 

Chlorin  Gas.  Charcoal. 

Hydrogen  Dioxid.  Sulphurous  Acid. 

Diaphoretics  or  Sudorifics. — These  are  agents  which  promote 
the  secretion  of  sweat.     When  the  action  of  the  remedy  is  such  that 


DEFINITIONS   OF   REMEDIES  ^^ 

the  perspiration  stands  in  beads  upon  the  surface,  it  is  called  sudorific. 
Examples  are: 

Pilocarpus  (Pilocarpin).  Ammonium  Acetate. 

Dover's  Powder.  Spirit  of  Nitrous  Ether. 

Disinfectants  or  Germicides. — These  are  agents  which  destroy 
microorganisms  and  their  spores.     Examples  are: 

Mercuric  Chlorid.  Urotropin. 

Formaldehyd.  Hydrogen  Dioxid. 

Cresol.  Potassium  Permanganate. 

Phenol.  Silver  Compounds. 

Thymol.  Betanaphthol. 

Heat.  Chlorin  Gas. 

Diuretics. — These  are  agents  which  increase  the  flow  of  urine. 
Examples  are: 

Potassium  Salts.  Spirit  of  Nitrous  Ether  (Sweet 

Lithium  Salts.  Spirit  of  Niter). 

Effervescent  Salts. 

Emetics. — These  are  agents  which  produce  vomiting.  Exam- 
ples are: 

Ipecac.  Alum. 

Tartar  Emetic.  Mustard. 

Zinc  Sulphate.  Apomorphin. 

Copper  Sulphate.  Tepid  Water,  in  quantity. 

Emollients. — These  are  substances  which  protect,  soften,  and 
relax  the  tissues  to  which  they  are  applied.     Examples  are: 

Hot  Fomentations.  Linseed  Oil. 

Poviltices.  Petroleum. 

Lard.  Cacao  Butter. 

LanoHn.  •  Glycerin. 

Olive  Oil.  Almond  Oil. 

Escharotics  or  Caustics. — These  are  agents  which  destroy  the 
tissues  upon  which  they  act.     Examples  are: 

Mineral  Acids.  Osmic  x\cid. 

Caustic  Alkalies.  Zinc  Chlorid, 

Phenol.  Sodium  Ethylate. 

Arsenic  Trioxid.  Mercuric  Chlorid. 

Trichloracetic  Acid.  Silver  Nitrate. 

Actual  Cautery. 

Expectorants. — These  are  agents  which  modify  the  secretion 
of  mucus  from  the  mucous  membrane  of  the  air-passages  and  facilitate 
its  expulsion.     Examples  are: 


34  DEFINITIONS    OF    REMEDIES 

Ammonium  ChJorid.  Squill. 

Eucalyptus.  Ipecac. 

Potassium  Citrate. 

Hypnotics  or  Somnifacients. — These  are  agents  which  produce 
sleep.     Examples  are: 

Chloral  Hydrate.  Pyramidon. 

Butyl-chloral  Hydrate.  Trional. 

Sulphonal.  Paraldehyd. 

Opium  (and  Alkaloids)-.  The  Bromids. 

Irritants. — These  are  agents  which,  when  applied  to  the  skin  or 
mucous  membrane  of  the  mouth,  cause  active  hyperemia  or  inflam- 
mation. When  they  are  applied  not  simply  for  their  local  action, 
but  to  influence  favorably  a  deep-seated  part  which  is  diseased,  they 
are  called  counterirritants.  Irritants  are  largely  used  for  the 
latter  purpose  in  dental  practice.     Examples  are: 

lodin.  Aconite. 

Mustard.  Chloroform. 

Capsicum.  Volatile  Oils. 

Camphor.  Menthol. 

Mydriatics. — These  are  agents  which  produce  dilatation  of  the 
pupil  of  the  eye.     Examples  are: 

Atropin.  Homatropin. 

Hyoscyamin.  Cocain. 

Anesthetics  (late  in  their  action). 

Myotics. — These  are  agents  which  produce  contraction  of  the 
pupil  of  the  eye.     Examples  are: 

Physostigma,  Eserin.  Anesthetics    (early    in    their    ac- 

Opium,  Morphin.  tion.) 

Narcotics. — These  are  agents  which  produce  stupor.  Examples 
are: 

Opium  (and  Alkaloids).  Chloroform. 

Alcohol.  Ether. 

Restoratives. — These  are  agents,  somewhat  similar  to  altera- 
tives, which  promote  constructive  metamorphosis.  Restoratives 
include : 

FOODS,  HEMATICS,  AND  TONICS 

Foods  are  substances  which,  when  introduced  into  the  body, 
supply  material  to  renew  some  structure  or  to  maintain  some  vital 
process.  They  differ  from  medicines  in  that  the  latter  modify  vital 
processes,  but  furnish  no  material  to  sustain  such. 


DEPINITIONS    OF   REMEDIES  35 

Hematics  are  medicines  which  increase  the  hematin  in  the  blood, 
and  enrich  the  red  blood-corpuscles.  The  compounds  of  iron  are 
the  principal  hematics. 

Tonics  are  agents  which  improve  the  tone  and  give  strength  and 
energy  to  the  tissues.     Among  the  tonics  are: 

Iron  and  Compounds.  Cod-liver  Oil. 

Phosphorus.  Nux  Vomica. 

Calcium  Phosphate.  Cinchona. 

Hypophosphites.  Arsenic. 

Sedatives. — These  are  agents  which  exert  a  soothing  influence 
on  the  system  by  lessening  functional  activity  and  diminishing  pain. 
They  have  been  largely  considered  in  other  classes  of  remedies,  as: 
General  sedatives  include  anesthetics  and  narcotics.  Nervous  sedatives 
include  the  bromids,  tobacco,  etc. 

Sialogogues. — These  are  agents  which  stimulate  the  salivary 
and  buccal  mucous  glands,  increasing  the  secretion  and  flow  of 
saliva  and  buccal  mucus.  Holding  the  mouth  open,  as  in  dental 
operations,  changes  the  character  and  flow  of  the  mouth  secretions. 
Examples  of  drugs  producing  this  effect  are: 

Pilocarpus  (Jaborandi).  lodin  Compounds. 

Mercurials.  Tobacco.  * 

Echinacea,  Echafolta.  Potassium  Chlorate. 

Stimulants. — These  are  agents  which  increase  the  activity  of 
an  organic  function  or  process.  When  applied  to  medicinal  agents 
the  term  is  used  in  various  senses,  for  different  agents  stimulate  the 
functional  activity  of  the  various  organs  of  the  body.  As  examples 
we  have: 


Cardiac. 

Respiratory. 

Gastric.               Restorative. 

Strychnin. 

Atropin. 

Gentian.             Physiologic  Salt  Solution. 

Digitahs. 

Bitter  Tonics. 

Caffein. 

Alcohol. 

St3^tics  and  Hemostatics. — These  are  agents  which  arrest  hemor- 
rhage. When  the  agent  is  applied  locally  it  is  called  a  Styptic; 
when  administered  internally  it  is  called  a  Hemostatic.  Examples 
are: 

Styptics.  Hemostatics. 

Acids.  .   Ergot. 

Alum.  GaUic  Acid. 

Ferric  Subsulphate.    ''  Hamamelis. 

Adrenalin  Chlorid. 

Cauterization. 


36  DRUGS 


DRUGS 

As  stated  elsewhere,  an  effort  will  be  made  to  divide  drugs  into 
local  and  general  remedies,  and  group  them,  so  far  as  possible,  accord- 
ing to  their  physiologic  action  and  therapeutic  application.  Those 
drugs  which  are  largely  applied  locally  in  dental  practice  will  first 
be  considered. 

LOCAL  REMEDIES 

ANTACIDS 

Antacids  are  agents  which  neutralize  acids  by  virtue  of  their 
alkaline  or  basic  property.  All  acids,  whether  mineral  or  organic, 
have  a  destructive  action  on  the  tooth-structure.  Acids  are  found 
in  the  mouth  as  a  result  of  the  fermentation  of  carbohydrate  food- 
stuffs, from  eructations  of  the  stomach,  and  from  perverted  buccal 
mucous  glands.  Agents  which  are  capable  of  neutralizing  acids, 
therefore,  have  an  important  role  to  play  in  the  broad  field  of  oral 
prophylaxis.  They  form  the  base  of  nearly  all  dentifrices  and  enter 
as  an  essential  constituent  into  most  of  the  mouth-washes  on  the 
market.     The  most  important  antacids  are : 

Precipitated  Calcium  Carbonate.      Sodium  Borate  (Borax). 
Lime-water.  Magnesium  Oxid. 

Sodium  Bicarbonate.  Soap. 

CALCn  CARBONAS  PRS:CIPITATUS— U.S.P. 

(Precipitated  Calcium  Carbonate;  Precipitated  Chalk;  CaCOs.) 

Formerly  there  were  two  official  forms  of  chalk :  Precipitated  cal- 
cium carbonate  and  prepared  chalk.  The  former  is  the  only  form  rec- 
ognized in  the  U.S.P.  IX  and  is  made  by  mixing  aqueous  solutions 
of  calcium  chlorid  and  sodium  carbonate,  the  resulting  precipitate 
of  calcium  carbonate  being  purified.  The  latter  is  native  calcium 
carbonate,  freed  from  most  impurities  by  elutriation  (washing). 
Precipitated  calcium  carbonate  occurs  as  a  fine,  white,  micro-crys- 
talline powder,  odorless  and  tasteless,  and  permanent  in  the  air, 
nearly  insoluble  in  water;  the  solubility  is  increased  by  the  presence 
of  ammonium  salts  and  especially  by  carbon  dioxid.  It  is  insoluble 
in  alcohol.     The  average  dose  is  15  gr.  (i.o  Gm.). 

Therapeutics. — Chalk  is  an  antacid  and  mild  astringent.  It  is 
an  excellent  antacid  when  the  acidity  of  the  fluids  of  the  mouth  is 
due  to  eructations  from  the  stomach.     It  may  be  prescribed  as  an 


LIQUOR   CALCIS — SODII  BICARBONAS  37 

antidote  in  general  poisoning  by  any  of  the  mineral  acids  or  by  oxalic 
acid,  care  being  taken  to  avoid  the  rapid  evolution  of  large  quantities 
of  gas  (CO2).  Because  of  its  antacid  properties  and  its  almost 
absolute  insolubility,  it  enters  into  the  composition  of  nearly  all 
dentifrices,  forming  the  base  of  most  tooth-powders  and  pastes. 

LIQUOR  CALCIS— U.S.P. 

(Solution  of  Calcium  Hydroxid;  Lime-water;  Ca(0H)2.) 

Lime-water  is  a  saturated  solution  of  pure  calcium  hydroxid  in 
water.  The  liquid  should  be  clear  and  colorless,  without  odor,  and 
having  a  saline  and  feebly  caustic  taste.  It  should  contain  not  less 
than  0.14  per  cent,  of  calcium  hydroxid.  When  administered  in- 
ternally the  average  dose  is  4  fl.  dr.  (15.0  mils).  A  useful  official 
preparation  is  Linimentum  Calcis  (equal  volumes  of  lime-water  and 
linseed  oil). 

Therapeutics. — In  all  cases  where  cows'  milk  is  the  chief  article 
of  diet,  as  in  the  artificial  feeding  of  children,  lime-water  should  be 
added  to  the  milk  to  prevent  the  formation  of  hard  curds  in  the 
stomach.  In  cases  of  obstinate  vomiting,  as  in  pregnancy,  when  the 
vomiting  or  eructations  are  due  to  a  high  degree  of  acidity,  it  is  a 
useful  remedy.  In  chronic  catarrh  with  an  excessive  secretion  of 
mucus,  lime-water  diluted  with  two-thirds  cinnamon  water,  to  which 
a  smaU  amount  of  alcohol  is  added,  can  be  used  as  a  spray  and  for 
rinsing  the  mouth  and  brushing  the  teeth,  gums,  and  tongue  with 
gratifying  results.  The  official  Hniment,  called  also  Carron  Oil, 
is  employed  as  a  soothing  application  for  hums  and  scalds. 

SODH  BICARBONAS— U.S.P. 

(Sodium  Bicarbonate;  NaHCOa.) 

Sodium  bicarbonate  is  a  white,  opaque  powder,  without  odor, 
and  having  a  cooHng  and  slightly  alkaline  taste.  It  is  freely  soluble 
in  water,  i  part  dissolving  in  10  parts  of  water  at  25°C.;  insoluble 
in  alcohol.  The  average  dose  is  15  gr.  (i.o  Gm.).  An  important 
official  preparation  is : 

TrocMsci  Sodii  Bicarbonatis  (containing  about  2)4,  gr.  (0.18 
Gm.)  each). 

Therapeutics. — Sodium  bicarbonate  is  extensively  used  to 
neutralize  the  excess  of  hydrochloric  acid  or  abnormal  acids  in  the 
stomach.     Given  in  the  form  of  a  troche  an  hour  or  two  before 


38  ANTACIDS 

meals,  it  allays  the  burning  pain,  eructations,  and  palpitations  caused 
by  the  acids  of  fermentation. 

Sodium  bicarbonate  is  often  applied  externally  as  a  sedative 
dressing  for  superficial  burns.  A  5  to  10  per  cent,  solution  has  been 
used  in  cases  of  thrush  with  excellent  results.  It  is  an  ingredient  of 
the  popular  Dobell's  solution  (see  p.  271)  and  used  as  an  antacid 
or  detergent  in  many  mouth-washes.  Sodium  bicarbonate  is  added 
to  the  water  in  which  instruments  are  boiled  for  sterilization  to 
prevent  the  latter  from  rusting.  Sodium  carbonate  and  borax 
are  also  used  for  this  purpose.  When  acids  are  employed  in  root- 
canals,  they  should  subsequently  be  neutralized  with  some  ant- 
acid, and  nothing  is  better  than  a  solution  of  sodium  bicarbonate. 
The  agent  not  only  neutralizes  the  excess  acid,  but  the  effervescence 
produced  removes  from  the  canal  all  of  the  "mushy"  and  disinte- 
grated material;  thus  leaving  it  clean  and  sterile.  The  powder  is 
used  by  direct  application  to  lessen  the  hypersensitiveness  of  dentin 
when  due  to  acidity.  In  the  treatment  of  pyorrhea  and  oral  prophy- 
laxis, the  teeth,  oftentimes  after  the  scaling  and  polishing,  are  ex- 
tremely responsive  to  thermal  changes,  especially  where  the  gums 
have  receded,  exposing  the  cementum.  This  can  be  controlled  by 
warm  solutions  of  the  drug. 

It  is  stated  in  many  clinical,  pharmacologic  and  physiologic 
text-books  that  the  alkaline  salts  of  sodium  promote  a  flow  of  gastric 
juice.  Pawlow,  Sippy,  Stone,  and  other  internists  claim  that 
clinical  experience  does  not  confirm  this  theory.  In  fact,  it  has 
been  shown  that  alkalies  exert  a  distinct  inhibitory  influence  on  the 
gastric  glands,  separate  and  distinct  from  their  neutralizing  effects 
on  acids  already  present  in  the  stomach.  Sodium  bicarbonate  20 
parts,  heavy  magnesium  oxid  5  parts,  and  bismuth  subcarbonate 
5  parts  make  an  excellent  "alkaline  powder"  to  be  taken  after 
meals  in  from  one-half  to  one  teaspoonful  doses  in  cases  of  hyper- 
acidity oj  the  stomach,  gastric  and  duodenal  ulcers.  The  powder 
should  be  taken  in  a  small  quantity  of  water,  thoroughly  agitated, 
as  the  magnesia  oxid  and  bismuth  salt  do  not  dissolve  in  the  water. 

Incompatibilities. — Sodium  bicarbonate  is  incompatible  with 
acids,  metallic  salts,  and  alkaloids. 

SODII  BORAS— U.S.P. 

(Sodium  Borate;  Sodium  Pyroborate;  Borax;  Na2B407-ioH2O.) 

Borax  occurs  in  colorless,  transparent,  monoclinic  prisms,  or 
white  powder;  inodorous,  and  of  a  sweetish,  alkaline  taste.     It  is 


MAGNESII   OXIDUM  39 

soluble  in  about  i6  parts  of  water  and  i  part  of  glycerin,  and  is 
insoluble  in  alcohol.  The  average  dose  is  12  gr.  (0.75  Gm.).  An 
ofl&cial  preparation  for  external  use  containing  a  small  amount  of 

borax  is: 

Unguentum  Aquae  Rosse  (Cold  Cream). 

Theapeutics. — The  alkaline  and  antiseptic  properties  of  borax 
make  it  a  useful  drug.  It  is  a  valuable  ingredient  in  mouth-washes 
possessing  the  above  qualities,  and  can  be  used  freely  in  saturated 
solution  {6}4  per  cent.)  in  cases  of  stomatitis  and  in  thrush.  In  the 
latter  disease,  which  generally  occurs  in  the  mouths  of  infants  where 
it  is  impracticable  to  use  a  mouth-wash  to  advantage,  a  saturated 
solution  in  glycerin,  made  by  dissolving  the  drug  in  hot  glycerin, 
can  be  employed.  This  thick,  sweet  solution  should  be  appHed 
by  means  of  a  swab  to  the  mucous  membranes  of  the  infant's  mouth. 
A  saturated  solution  in  a  10  per  cent,  formaldehyd  solution  makes 
an  excellent  sterilizing  fluid  for  small  instruments.  The  borax 
prevents  the  formaldehyd  from  attacking  the  metal.  A  good 
coUyrium  (eye-water)  can  be  made  by  adding  2  per  cent,  of  borax 
to  a  saturated  solution  of  boric  acid. 

IncompatibiUties. — Borax  is  incompatible  with  acids,  metallic 
salts,  and  alkaloids,  and  glycerin  slowly  converts  it  into  boric  acid. 

MAGNESn  OXIDUM— U.S.P. 
(Magnesium  Oxid;  Light  Magnesia;   Calcined  Magnesia;  MgO.) 

Light  Magnesia  is  a  white,  very  bulky,  and  very  fine  powder, 
without  odor,  and  having  an  earthy-Hke  taste.  It  is  practically 
insoluble  in  water,  and  insoluble  in  alcohol,  but  chemically  soluble 
in  dilute  acids.  The  average  dose  is  30  gr.  (2.0  Gm.).  An  important 
official  preparation  is: 

Ferri  Hydroxidum  cum  Magnesii  Oxido  (Arsenic  Antidote). 

Therapeutics. — The  preparation  of  ferric  hydrate  with  magnesia 
has  long  been  recognized  as  an  efficient  antidote  in  arsenical  poison- 
ing. Other  compounds  of  magnesia,  recognized  by  the  U.S. P.,  are 
Heavy  Magnesia  (Magnesia  Oxid — $^2  times  as  heavy  as  Ught 
magnesia)  and  Magnesium  Carbonate.  Both  have  practically  the 
same  properties  and  uses  as  light  magnesia.  Magnesium  carbonate, 
however,  should  be  used  cautiously  when  there  is  much  acid  in  the 
stomach  on  account  of  the  unpleasant  eructations  of  gas  (CO2). 
Magnesium  carbonate,  being  cheap  and  insoluble,  is  often  substi- 
tuted for  talc  or  precipitated  calcium  phosphate  in  the  preparation 


40  ANTACIDS 

of  the  aromatic  waters/  The  suspended  precipitate  of  magnesium 
hydrate,  commercially  called  milk  of  magnesia,  is  a  useful  antacid. 
In  cases  of  erosion  of  the  teeth,  in  pregnancy,  and  other  conditions 
wherein  the  mouth  secretions  are  acid  in  reaction,  it  can  be  used  to 
advantage  by  coating  the  exposed  tooth-surfaces  with  it.  Its 
gelatinous  consistence  causes  it  to  adhere  and  remain  for  a  consider- 
able length  of  time,  especially  if  applied  on  retiring  at  night  when  the 
jaws  and  buccal  tissues  are  at  rest. 

In  cases  of  hyperacidity  of  the  stomach,  due  either  to  an  excess  of 
■  hydrochloric  acid  or  the  acids  of  fermentation,  Sippy  recommends  an 
average  dose  (30  gr.-2.o  Gm.)  each  of  heavy  magnesia  and  sodium 
bicarbonate;  this  to  be  taken  in  a  small  amount  of  water  soon  after 
each  meal.  Besides  these  antacids,  the  proper  diet  must  be  observed 
and  I  fl.  oz.  (30.0  mils)  each  of  milk  and  cream  should  also  be  taken 
after  the  meal.  Magnesia  is  partly  converted  by  the  acids  of 
the  stomach  into  soluble  salts  that  act  as  laxatives;  hence,  when  inter- 
nally administered,  the  antacid  properties  of  magnesia  are  combined 
with  those  of  a  mild  aperient  or  laxative. 

SAPO— U.S.P. 

(Soap;  White  Castile  Soap.) 

The  only  official  soap  is  white  castile  soap,  made  by  boiling  olive 
oil  with  sodium  hydroxid.  Any  fat  boiled  with  sodium  or  potassium 
hydroxid  will  form  soap.  Hard  soap  is  a  sodium  soap,  soft  soap  is  a 
potassium  soap.  White  castile  soap  should  be  hard,  but  easily  cut 
when  fresh,  easily  pulverized  when  dry,  and  free  from  rancid  odor. 
It  has  a  rather  unpleasant  taste  and  an  alkaline  reaction,  hence  it 
is  an  antacid,  soluble  in.  water  and  in  alcohol. 

A  useful  preparation  is: 

Linimentum  Saponis  Mollis — U.S.P.  (Liniment  of  Soft  Soap, 
Tincture  of  Green  Soap). 

Therapeutics. — White  castile  soap  is  alkaline  in  reaction  and 
somewhat  antiseptic,  possessing  detergent  properties  to  a  marked 
degree.  The  greatest  value  of  soap  lies  in  its  power  to  dissolve  fats. 
Advantage  is  taken  of  this  fact  in  bleaching  teeth,  as  will  be  explained 
in  Practical  Therapeutics  (p.  407).  White  castile  soap  is  chiefly 
used  in  dental  practice  as  a  constituent  of  dentifrices,  both  tooth- 
powders  and  tooth-pastes.  The  preparation  should  not  contain  more 
than  about  15  per  cent.;  for,  in  greater  quantities,  too  much  suds  is 
formed  in  the  mouth  by  its  employment.  The  preparation  known 
as  tincture  of  green  soap  is  a  valuable  toilet  article  for  dentists'  hands. 


ANTISEPTICS,  DISENFECTANTS,  AND  DEODOEANTS  4 1 

Incompatibilities. — Soap  is  incompatible  with  all  acids  and 
with  earthy  and  metallic  salts.  It  is  precipitated  in  hard  water  (con- 
taining earthy  salts)  as  an  insoluble  soap. 

ANTISEPTICS,  DISINFECTANTS,  AND  DEODORANTS 

The  term  antiseptic  has  been  defined  elsewhere  as  applying  to 
that  class  of  remedies  which  inhibit  or  have  a  restraining  influence 
on  the  life  and  activity  of  microorganisms.  The  terms  disinfectant 
and  germicide  have  been  previously  referred  to  as  applying  to  that 
class  of  remedies  which  destroy  microorganisms  and  their  spores. 
Some  authors  have  endeavored  to  distinguish  between  the  two  latter 
terms,  using  the  term  germicide  in  the  sense  that  the  agent  simply 
kills  the  germ,  and  disinfectant  in  the  sense  that  the  agent  not  only 
kills  the  germ,  but  also  acts  upon  the  noxious  products  of  putrefac- 
tion and  fermentation.  As  a  matter  of  fact,  this  distinction  is  largely 
theoretical,  for  there  are  few  agents  which,  if  used  in  sufficient 
strength  to  kill  the  germ,  will  not  also  act  upon  and  thus  destroy  or 
remove  the  by-products  of  germ-growth.  In  this  work,  therefore, 
the  term  disinfectant  will  be  used  in  preference  to  the  term  germicide, 
and  for  the  reason  given.  A  deodorant  is  an  agent  which  destroys 
offensive  odors,  and  inasmuch  as  the  odor  generally  comes  from  the 
noxious  products  of  putrefaction,  the  deodorization  results  from  true 
disinfection.  Therefore,  deodorants  will  be  discussed  conjointly 
with  antiseptics  and  disinfectants. 

Many  agents  belong  to  both  the  antiseptic  and  disinfectant 
classes  of  remedies,  depending  upon  the  strength  in  which  they  are 
employed.  In  weak  solutions  they  act  as  antiseptics;  in  strong  solu- 
tions, as  disinfectants.  These  two  classes  of  remedies  are  among  the 
most  important  classes  employed  in  dental  practice,  and  it  is  well 
that  the  student  should  understand  at  the  outset  the  significance  of 
these  remedies. 

In  all  surgical  work  the  ideal  condition  sought  is  the  absence  of 
disease-producing  germs  (asepsis),  rather  than  to  depend  upon  the 
chemic  destruction  of  them  at  the  time  of  operating.  With  this  end 
in  view,  the  instruments  are  sterilized  by  boiling,  and  the  site  of 
operation  as  well  as  the  operator's  hands  are  disinfected  by  washing 
in  certain  solutions.  Strictly  speaking,  infected  animal  tissue  cannot 
be  sterilized  by  employing  disinfectants.  An  ideal  disinfectant 
would  be  an  agent  which,  employed  in  certain  strength  solution  in  a 
septic  process  or  disease,  would  kill  the  disease-producing  germ  and 
destroy  or  remove  the  poisonous  by-products  without  acting  deleteri- 


42  ANTISEPTICS,    DISINFECTANTS,    AND   DEODORANTS 

ously  upon  the  animal  cell.  But  bacteriologists  inform  us  that  the 
cell-wall  of  a  vegetable  cell  (.bacteria)  is  less  permeable  to  disinfecting 
agents  than  is  the  cell-wall  of  the  animal  cell.  -Therefore,  in  our 
present  state  of  knowledge  we  should  not  employ  disinfectants  in  our 
effort  to  kill  the  germ  when  its  habitat  is  among  living  animal  cells. 
It  becomes  necessary,  then,  to  attack  these  germs  in  another  manner. 
This  can  be  done  by  the  use  of  certain  antiseptic  agents  which  check 
the  growth  and  activity  of  the  germs,  cripple  them,  as  it  were,  and 
which  agents  also  are  just  sufficiently  irritating  to  the  animal  cells 
to  produce  stimulation.  This  stimulating  or  awakening  process 
on  the  part  of  the  animal  cells  will  cause  the  latter  to  attack  and  des- 
troy the  already  crippled  vegetable  cells,  thus  bringing  about  nature's 
method  of  steriHzation. 

When  the  germs  which  we  are  endeavoring  to  destroy  are  among 
the  contents  of  a  gangrenous  root-canal,  for  example,  surrounded  by 
hard  tooth-structure  and  removed  from  live  animal  tissue,  the  prob- 
lem presents  an  entirely  different  aspect.  Here  true  disinfectants 
can  be  employed.  The  fact  that  a  remedy  will  destroy  microorganic 
life  in  a  certain  length  of  time  in  a  test-tube,  or  in  a  gangrenous  root- 
canal,  is  no  criterion  that  the  remedy,  as  such,  can  be  used  for  disin- 
fecting the  soft  tissues  of  the  mouth. 

The  chief  antiseptics  are: 

Boric  Acid.  Many  VolatUe  Oils: 

^  Borax.  OU  of  Cajuput. 

^  Benzoic  Acid.  OU  of  Cinnamon. 

"^  Salicylic  Acid.  -     ^     OH  of  Cloves. 

•  Salol.  "    s    ^^'    OU  of  Eucalyptus. 

Salophen.  v     Oil  of  Peppermint. 

"*  Sodium  Salicylate.  OU  of  Thyme. 

lodin  and  Compounds.  Charcoal. 

Betanaphthol.  \         Calendula. 

Resorcin.  Arnica. 

SUver  Compounds.  Myrrh. 

Ozone  and  Oxygen. 

The  chief  disinfectants  are: 

Mercuric  Chlorid  (Discussed  Urotropin. 

.       under  Mercury  in  Alteratives).  Hydrogen  Dioxid. 

''  Phenol.  Potassium  Permanganate. 

N»  Cresols.  Chinosol. 

Creosote.  Heat. 

Formaldehyd. 


ACmUM  BORICUM  43 

ACmUM  BORICUM— U.S.P. 

(Boric  Acid;  Boracic  Acid;  H3BO3.) 

Boric  acid  occurs  in  transparent,  colorless,  pearly  scales  or 
crystals,  nearly  colorless  and  of  a  somewhat  bitterish  taste,  and 
slightly  unctuous  to  the  touch.  It  is  soluble  in  about  18  parts 
of  water  and  alcohol,  and  4  parts  of  glycerin  at  25°C.  When  given 
internally  the  average  dose  is  8  gr.  (0.5  Gm.). 

It  enters  into  two  official  preparations  which  are  valuable  in 
dental  practice.     They  are: 

Glyceritum  Boroglycerini,  Glycerite  of  Boroglycerin  (contains 
31  per  cent,  of  boric  acid  in  glycerin). 

Unguentum  Acidi  Borici,  Ointment  of  Boric  Acid  (10  per  cent.) . 
Liquor  Antisepticus,  Antiseptic  Solution  (contains  2  per  cent, 
of  boric  acid,  o.i  per  cent,  each  of  benzoic  acid  and  thymol, 
25  per  cent,  of  alcohol,  and  minute  quantities  of  eucalyptol, 
oil  of  peppermint,  oil  of  gaultheria,  and  oil  of  thyme,  in  an 
aqueous  vehicle).     N.F. 

Physiologic  Action. — Boric  acid  is  a  nonirritating  antiseptic  and 
deodorant.  In  quantities  generally  employed  by  dentists,  boric 
acid  produces  no  appreciable  symptoms.  It  is  rapidly  absorbed 
and  rapidly  eliminated  by  the  saliva,  perspiration,  feces,  and  urine 
— the  bulk  of  it  escaping  in  the  urine  within  twenty-four  hours 
after  its  administration.  It  is  not  a  drug  to  be  used  indiscrimi- 
nately, for  repeated  external  applications  have  led  to  the  same  train 
of  symptoms  as  those  observed  following  the  continued  internal 
administration  of  the  drug.  The  term  borism  has  been  appHed 
to  this  condition,  and  the  most  important  phenomena  are  digestive 
disturbances,  dryness  of  the  skin  and  mucous  membranes,  and  a 
tendency  toward  certain  rashes.  The  drug  has  been  used  as  a  pre- 
servative of  milk  and  foods,  and  there  is  a  difference  of  opinion 
among  investigators  as  to  whether  or  not  boric  acid  has  a  deleterious 
action  when  so  used. 

Therapeutics. — Boric  acid  is  a  constituent  of  many  mouth- 
washes. It  is  largely  employed  in  a  saturated  aqueous  solution 
(5  per  cent.)  as  an  antiseptic  and  stimulating  wash.  Because  of  its 
nonirritating  properties  it  can  be  applied  to  the  most  sensitive  tissue. 
A  good  collyrium  (eye-wash)  can  be  made  by  adding  10  gr.  (0.6  Gm.) 
of  borax  to  i  fl.  oz.  (30.0  mils)  of  the  saturated  solution  of  boric  acid. 
Lotions,  ointments,  and  dusting-powders  containing  boric  acid  are 
used  to  advantage  in  many  acute  inflammatory  conditions  of  the 
mucous  membranes  and  skin.  As  a  stimulating  and  antiseptic  mouth- 
wash there  are  few  better  than  the  formerly  official  liquor  antisepticus. 


44  ANTISEPTICS,   DISINFECTANTS,    AND    DEODORANTS 

Probably  the  only  objection  to  boric  acid  as  a  constituent  of 
mouth-washes  is  its  slightly  acid  reaction  and  rather  sparing  solu- 
bility in  water.  Whenever  a  stronger  solution  than  the  saturated 
is  desired,  the  official  glyceritum  boroglycerini  (glycerite  of  boro- 
glycerin)  can  be  used.  This  is  neutral  in  reaction  and  can  be  em- 
ployed in  full  strength  or  diluted.  However,  strong  solutions  should 
not  be  used  continuously  on  account  of  the  tendency  to  produce 
borism. 

Incompatibilities. — In  aqueous  solution  it  will  decompose  car- 
bonates and  bicarbonates. 


SODH  BORA.S— U.S.P. 

Borax. — This  salt  has  been  fully  discussed  under  Antacids  (see 
p.  38).  Its  antiseptic  and  alkaline  properties  give  it  a  prominent 
place  among  dental  remedies.  The  physiologic  action  of  borax 
closely  resembles  that  of  boric  acid,  for  which  it  is  often  substituted 
to  good  advantage,  especially  in  mouth-washes  where  it  is  desired 
to  have  an  alkaline  solution,  and  in  tooth-powders  and  pastes. 
Boric  acid,  as  well  as  all  other  acids,  is  incompatible  with  carbonates, 
and  as  calcium  carbonate  (chalk)  is  the  base  of  nearly  all  dentifrices, 
boric  acid  should  not  be  a  constituent.  Here  the  sodium  salt, 
borax,  can  be  employed  with  the  same  result  without  any  reaction 
(incompatibility)  between  the  ingredients  of  the  mixture. 

ACIDUM    BENZOICUM— U.S.P. 

(Benzoic  Acid;  HC7H5O2) 

Benzoic  acid  is  an  organic  acid  obtained  from  benzoin  and 
balsam  of  Peru,  or  prepared  synthetically.  It  occurs  in  white  or 
slightly  yellow  scales  or  needle-shaped  crystals  of  an  aromatic  odor 
and  taste.  It  is  sparingly  soluble  in  water,  but  with  an  equal 
quantity  of  borax  it  can  be  dissolved  to  the  extent  of  i  per  cent., 
freely  soluble  in  alcohol  and  glycerin.  The  average  dose  is  8  gr. 
(0.5  Gm.). 

Physiologic  Action. — Benzoic  acid  has  proven  to  be  an  antiseptic 
of  considerable  power.  Long  states  that  a  solution  of  i  1400  has 
been  found  to  destroy  developed  bacteria.  It  also  acts  as  a  stimu- 
lant to  mucous  membranes.  Internally  administered  it  increases, 
to  a  variable  degree,  the  nitrogenous  output  and  lessens  the  quantity 
of  ethereal  sulphates  and  indican  in  the  urine.     In  large  doses  benzoic 


ACIDUM  SALICYLICUM  45 

acid  and  benzoates  have  an  irritant  action  on  the  stomach,  and  in 
consequence  excite  nausea  and  vomiting  (Stevens), 

Therapeutics. — It  is  found  that  a  saturated  solution  of  borax 
(634  pei^  cent.)  will  dissolve  i  per  cent,  of  benzoic  acid  and  still  be 
alkaline.  This  is  doubtless  due  to  a  reaction  between  the  substances 
whereby  sodium  benzoate  is  formed,  which  is  freely  soluble.  In  this 
way  it  may  be  employed  as  a  constituent  of  mouth-washes.  It 
possesses  no  advantage  over  the  sodium  salt,  which  had  better  be 
employed  direct.  Sodium  benzoate  is  an  excellent  constituent  of 
dentifrices.  In  the  form  of  the  benzoates  it  has  been  recommended 
in  rheumatism  or  the  gouty  diathesis,  but  is  not  so  efficacious  as  the 
salicylates.  Balsam  of  Peru,  which  contains  benzoic  acid,  is  used 
externally  as  a  parasiticide  in  scabies  (itch) .  The  acid  is  frequently 
added  to  ointments  to  prevent  rancidity. 

Incompatibility. — Benzoic  acid  in  the  presence  of  moisture  will 
react  upon  carbonates  and  bicarbonates.  It  should  not  be  employed, 
therefore,  as  a  constituent  of  dentifrices  with  calcium  carbonate  as 
the  base. 

ACIDUM  SALICYLICUM— U.S.P. 

(Salicylic  Acid;  HC7H5O3.) 

Salicylic  acid  is  an  organic  acid  obtained  from  various  plants, 
especially  from  gaultheria  (wintergreen) ,  but  it  is  chiefly  prepared 
synthetically.  It  occurs  as  a  white  crystalline  powder,  or  in  fine 
needle-shaped  crystals,  or  as  a  bulky  crystalline  powder,  odorless, 
but  possessing  a  sweetish,  afterward  acrid  taste.  It  is  soluble  in 
about  460  parts  of  water,  13  parts  of  alcohol,  and  60  parts  of  glycerin 
at  25°C.     The  average  dose  is  12  gr.  (0.75  Gm.). 

Physiologic  Action. — Salicylic  acid,  like  many  other  drugs,  acts 
differently  upon  different  individuals  and  upon  the  same  individual 
at  different  times.  In  susceptible  subjects  even  small  doses  give 
rise  to  a  peculiar  feeling  of  fullness  in  the  head,  ringing  in  the  ears, 
and,  at  times,  interference  with  the  senses  of  hearing  and  sight, 
causing  deafness  and  dimness  of  vision.  It  enters  the  circulatory 
fluids  as  an  alkaline  salicylate,  and  is  eliminated  from  the  body  in 
most  of  the  secretions,  but  principally  in  the  urine.  It  is  claimed 
on  good  authority  that  it  increases  the  output  of  urea  and  uric  acid. 

Therapeutics. — This  drug  must  be  classed  with  our  best  anti- 
septics. MiUer  has  shown  that  a  i  per  cent,  solution  of  saHcylic  acid 
will  disinfect  the  mouth,  as  ordinarily  considered,  in  one-quarter  of  a 
minute.     It  must  not  be  forgotten,  however,  that  the  mouth  cannot 


4  6  AXTISEPTICS,    DISIXFECTAXTS,    AND    DEODOEAXTS 

be  disinfected  in  the  true  sense  of  the  term.  Its  sparing  solubility  in 
water  and  its  acid  character  render  it  practically  useless  as  a  constitu- 
ent of  mouth-washes,  unless  a  salt,  like  borax,  or  alcohol  be  added  to 
the  solution.  The  chief  use  of  salicylic  acid  and  its  compounds  is 
in  acute  rheumatism,  in  which  condition  they  are  considered  specific 
remedies.  In  some  diseases,  as  certain  kinds  of  pyorrhea  alveolaris, 
which  seem  to  be  related  to  the  rheumatic  diathesis,  salicylic  com- 
pounds have  proven  to  be  efficacious.  Dissolved  in  collodion,  a 
dram  (4.0  Gm.)  to  the  ounce  (30.0  mils),  it  has  been  long  used  with 
success  in  removing  corns  and  warts. 

Incompatibilities. — Salicylic  acid  will  react  with  carbonates, 
potassium  chlorate,  and  potassium  permanganate. 

PHENYLIS  SALICYLAS— U.S.P. 

(Phenyl  Salicylate;  Salol;  C6H5C7H5O3.) 

Salol  is  prepared  by  heating  salicylic  acid  with  phenol  in  the 
presence  of  phosphorus  pentachlorid.  It  occurs  as  a  white  crystalline 
powder,  of  a  faintly  aromatic  odor,  and  slightly  sweetish  taste;  prac- 
tically insoluble  in  water,  but  soluble  in  alcohol,  and  freely  so  in  ether, 
chloroform,  and  in  fixed  and  volatile  oils.  The  average  dose  is  5  gr. 
(0.3  Gm.). 

Physiologic  Action. — Salol  acts  as  an  antiseptic  Hke  either  of 
its  constituents,  salicylic  acid  and  phenol.  It  is  not  a  disinfectant, 
as  it  wiU  not  destroy  bacteria,  although  it  prevents  their  proliferation. 
It  differs  from  sahcylic  acid  in  its  action  in  that  it  is  not  irritating  to 
the  mucous  membrane.  Salol  resists  to  a  great  extent  the  action  of 
the  gastric  juice,  passing  through  the  stomach  practically  unchanged, 
but  is  gradually  broken  up  in  the  intestine  by  the  alkaHne  fluids  into 
salicyHc  acid  (60  parts)  and  phenol  (40  parts). 

Therapeutics. — On  account  of  its  insolubility  in  water,  salol  is 
not  employed,  to  any  extent,  as  a  local  antiseptic,  except  at  times  in 
alcohoHc  solution,  as  in  mouth-washes.  We  find  its  chief  use  as  an 
intestinal  antiseptic.  Like  other  saHcyHc  compounds,  it  is  used  in 
the  various  forms  of  rheumatism.  It  may  be  prescribed  in  powders 
or  capsules  in  diarrheas  and  other  intestinal  fermentations.  Large 
doses  must  be  avoided  on  account  of  the  possible  poisoning  by  phenol, 
which  is  Uberated. 

In  cases  of  neuralgia  associated  with  rheumatism,  the  salicylates 
combined  with  some  hypnotic  drug  are  especially  indicated.  A 
powder  composed  of  5  gr.  (0.3  Gm.)  of  salol  and  4  Gr.  (0.27  Gm.)  of 
phenacetin  to  the  dose  is  a  useful  combination. 


ASPmiN — SALOPHEN  ,  47 

ASPIRIN  (Nonofficial) 
(Acetyl-saKcylic   Acid;    C9H8O4.) 

Aspirin  is  the  acetyl  derivative  of  salicylic  acid.  It  is  prepared 
by  the  prolonged  heating  of  50  parts  of  salicylic  acid  and  75  parts  of 
acetic  anhydrid  at  about  i5o°C.  under  a  reflux  condenser,  and  sub- 
sequently purified  by  recrystallization  from  chloroform.  It  occurs  in 
the  form  of  smaU,  colorless,  crystalline  needles,  odorless,  and  ha\'ing 
an  acidulous  taste;  soluble  in  100  parts  of  water,  freely  soluble  in 
alcohol  and  ether.  Boiling  water  decomposes  the  drug  into  acetic 
acid  and  salicylic  acid  or  a  salicylate.  The  average  dose  is  5  gr.  (0.3 
Gm.)  in  capsules  or  wafers.  It  should  be  dispensed  in  wax  paper,  free 
from  moisture. 

Physiologic  Action  and  Therapeutics. — Aspirin  passes  through 
the  stomach  unchanged,  the  decomposition  being  in  the  intestine. 
Its  action  is  similar  to  that  of  saHcylic  acid,  over  which  it  possesses 
the  advantage  of  producing  less  of  the  undesired  local  and  systemic 
side  effects,  due  to  the  slow  Uberation  and  assimilation  of  the  salicylic 
acid.  The  promiscuous  use  of  aspirin  by  the  laity,  especially  for 
the  relief  of  headache,  has  frequently  led,  even  in  small  doses,  to 
cases  of  rather  severe  poisoning;  the  chief  symptoms  being  edema 
(swelling)  of  the  lips,  tongue,  eyelids,  nose,  or  entire  face,  and  occa- 
sionally an  erythematous  rash.  Some  individuals  are  especially 
susceptible  to  the  drug  and  these  s}Tnptoms  are  usually  ascribed  to 
an  idiosyncrasy.  Aspirin  is  especially  useful  in  cases  of  rheumatism 
of  a  neuralgic  character. 

Incompatibles. — Heat,  moisture,  alkalies,  their  carbonates  and 
bicarbonates.     It  keeps  well  when  properly  protected. 

SALOPHEN  (Nonofficial) 
(Acetyl-paramino-phenyl  Salicylate;  C7H5O2.) 

Salophen  is  an  unofficial  compound  of  saHcylic  acid,  and  is  pre- 
pared by  a  chemic  process  similar  to  that  of  preparing  salol.  It 
occurs  in  white  scales,  tasteless  and  odorless;  insoluble  in  water,  but 
soluble  in  alcohol  and  ether.  The  average  dose  is  5  gr.  (0.3  Gm.) .  On 
account  of  the  liability  to  poisoning  from  the  phenol  which  is  liberated 
in  the  intestine  from  salol,  this  compound  was  introduced.  It  con- 
tains about  50  per  cent,  of  saHcylic  acid,  and  is  decomposed  by  the 
alkaHne  fluids  of  the  intestine  into  saHcyHc  acid  and  a  comparatively 
nonpoisonous   compound,   acetyl-paramino-phenyl.     The  action  of 


48  ANTISEPTICS,    DISINPECTANTS,    AND   DEODORANTS 

salophen  is  similar  to  that  of  other  salicylic  compounds.  While  it  is 
not  as  efl&cacious  in  rheumatism  as  sodium  salicylate,  being  tasteless 
and  unirritating  to  the  stomach  it  can  be  given  before  meals  in  the 
milder  manifestations  of  the  disease.  In  cases  of  neuralgia  of  rheu- 
matic origin  associated  with  acute  pain,  salophen  may  be  combined 
with  such  drugs  as  phenacetin  and  codein  sulphate.  A  powder  com- 
posed of  5  gr.  (0.3  Gm.)  each  of  salophen  and  phenacetin  and  J-^  gr. 
(0.016  Gm.)  codein  sulphate  is  a  valuable  combination. 

SODH '  SALICYLAS— U.S.P. 

(Sodium  Salicylate;  NaCyHsOs.) 

Sodium  salicylate  occurs  as  a  white  amorphous  powder,  without 
odor,  but  of  a  sweetish,  saline  taste.  It  is  freely  soluble  (0.9  part) 
in  water,  in  9  parts  in  alcohol,  and  in  glycerin  at  25°C.  The  aver- 
age dose  is  15  gr.  (i.o  Gm.). 

Physiologic  Action  and  Therapeutics. — The  action  of  this  salt 
is  the  same  as  that  of  salicyhc  acid.  It  has  the  advantage,  however, 
of  being  more  soluble  and  less  irritating  to  the  stomach.  It  is  prob- 
ably the  most  generally  used  of  all  the  salicylic  compounds,  and  is 
especially  indicated  in  the  acute  stage  of  rheumatism.  In  cases  of 
pyorrhea  associated  with  rheumatism  it  may  be  given  in  5  gr.  (0.3 
Gm.)  doses  after  meals,  well  diluted  with  water. 

Sodium  sahcylate  is  discussed  here  more  because  of  its  relation 
to  the  previously  considered  drugs  than  because  of  its  antiseptic 
properties.     It  is  not  considered  a  very  efficient  antiseptic.  ^_^,_ 

VOLATILE  OIL  GROUP  ^ 

A  true  classificauon  of  this  general  group  is  not  practicable.  The 
volatile  oils  vary  so  markedly  in  their  physical  and  chemic  make-up 
that  only  those  which  possess  antiseptic  properties,  and  are  employed 
in  dental  practice  as  such,  will  be  considered  here.  As  a  class  the 
volatile  oils  have  enjoyed  a  wide  range  of  usefulness  as  antiseptic 
remedies  in  the  past.  They  are  sparingly  soluble  in  water,  but  freely 
soluble  in  alcohol.  Some  are  useful  remedies  to  be  applied  to 
carious  cavities  in  vital  teeth,  where  the  pulp  is  involved,  because  of 
their  penetrating  and  slightly  analgesic  properties.  Those  which  are 
just  sufficiently  irritating  to  stimulate  the  pulp  to  healthy  activity  are 
the  ones  especially  indicated  for  this  purpose.  These  will  be  men- 
tioned later.  For  years  the  volatile  oils  were  employed  in  an  effort 
to  disinfect  gangrenous  root-canals.     In  this  they  have  proved  to  be  a 


OLEUM  CAJUPUTI — CINNALDEHYDUM  .   49 

dismal  failure.  Here  the  noxious  products  of  pulp  decomposition 
are  surrounded  by  hard  tooth-structure  and  removed  from  live  ani- 
mal tissue;  therefore,  we  are  justified  in  using  true  disinfectants- 
agents  which  will  kill  the  germs  and  destroy  their  by-products.  To 
use  any  of  the  essential  oils  for  this  purpose  to-day,  is  but  to  adhere 
to  the  old  empirical  method  of  treatment. 

OLEUM  CAJUPUTI— U.S.P. 
(Oil  of  Cajuput.) 

Oil  of  cajuput  is  a  thin,  bluish-green,  volatile  oil  distilled  from 
the  fresh  leaves  and-^^w^gj  of  Melaleuca  Leucadendron,  a  small  tree 
growing  in  the  East  Indies.  It  has  a  camphoraceous  odor  and  an 
aromatic,  bitter  taste.  Its  chief  constituent  is  cineol,  of  which  it 
should  contain  not  less  than  55  per  cent,  by  volume.  The  average 
dose  is  8  min.  (0.5  mil). 

Physiologic  action  and  therapeutics  resemble  those  of  oil  of 
cloves  and  oil  of  eucalyptus. 

OLEUM  CASSLS:— U.S.P. 
(Oil  of  Cinnamon,  Oil  of  Cassia.) 

Oil  of  cinnamon  is  a  yellowish  or  brownish  volatile  oil  distilled 
from  the  bark  of  the  shoots  of  Cinnamomum  Cassia,  a  tree  which 
grows  in  China.  The  oil  is  sometimes  commercially  called  oil  of 
cassia,  and  the  U.S.P.  IX  recognizes  it  by  this  name.  A  species 
of  cinnamon  which  grows  in  the  Ceylon  Islands  produces  a  volatile 
oil  having  a  finer  flavor,  though  less  employed.  It  has  the  character- 
istic odor  of  cinnamon  and  a  spicy,  burning  taste.  The  chief  con- 
stituent of  oil  of  cinnamon  is  cinnamic  aldehyd,  formerly  ofiicial 
and  of  which  it  should  contain  not  less  than  80  per  cent,  by  volume. 
The  average  dose  is  3  min.  (0.2  mil).  There  are  two  official  prepara- 
tions of  oil  of  cinnamon;  both  are  valuable  in  dental  practice. 

Aqua  Cinnamomi  (Cinnamon  Water),  used  as  a  spray  and  as 
a  vehicle  for  mouth- washes. 

Spiritus  Cinnamomi  (Spir't  of  Cinnamon)  used  largely  as  a 
flavoring  agent. 

CINNALDEHYDUM    (Nonofficial) 
(Cinnamic  Aldehyd;  CgHsO.) 

Cinnamic  aldehyd.  is  a  colorless  liquid  obtained  from  the  oil  of 
cinnamon  or  prepared  synthetically.     It  has  a  cinnamon-like  odor, 


50  ANTISEPTICS,    DISINFECTANTS,   AND   DEODORANTS 

and  a  burning,  aromatic  taste.  Sparingly  soluble  in  water,  freely 
in  alcohol,  fixed  and  volatile  oils.  Pure  synthetic  cinnamic  aldehyd 
has  largely  displaced  the  natural  oil  of  cinnamon*  and  may  be  used 
for  nearly  all  purposes  for  which  the  latter  is  employed.  The  average 
dose  is  the  same  as  oil  of  cinnamon. 

Physiologic  Action. — Oil  of  cinnamon  and  cinnamic  aldehyd 
are  active  antiseptics.  Both  are  rather  irritant  to  the  pulp  and  peri- 
cemental membrane.  Cinnamon  is  an  agreeable  aromatic  stimu- 
lant, carminative,  and  stomachic.  It  is  also  claimed  to  possess 
feebly  astringent  properties.  It  enters  into  aromatic  fluid  extracts 
and  also  into  many  of  the  compound  tinctures. 

Therapeutics. — Oil  of  cinnamon  has  been  employed  in  root- 
canal  treatment,  but  because  of  its  irritant  properties  and  of  its 
liability  to  stain  the  tooth-structure,  it  should  be  used  cautiously, 
if  at  all.  It  is  a  constituent  of  Black's  1-2-3  mixture  which  con- 
tains oil  of  cassia  i  part,  oil  of  wintergreen  2  parts,  and  phenol 
(carbolic  acid)  3  parts.  The  most  practical  use  that  can  be  made  of 
oil  of  cinnamon  in  dental  practice,  however,  is  as  a  flavoring  agent. 
The  official  water  may  be  employed  as  a  vehicle  for  mouth-washes 
and  sprays.  Every  dentist  should  know  how  to  prepare  the  solu- 
tion (see  p.  9) ,  as  it  should  be  freshly  made  and  used  freely  in  prophy- 
lactic and  phyorrheal  treatment. 

OLEUM  CARYOPHYLLI— U.S.P. 

(Oil  of  Cloves.) 

Oil  of  cloves  is  a  thin,  pale  yellow,  volatile  oil  distilled  from 
cloves,  the  dried  flower  buds  of  Eugenia  Aromatica,  a  shrubby  ever- 
green, introduced  and  cultivated  in  the  East  Indies.  It  has  a  strong 
aromatic  odor  of  cloves  and  a  pungent,  spicy  taste.  The  oil  gradually 
becomes  darker  and  thicker  by  age  and  exposure  to  the  air.  Its 
chief  constituent  is  eugenol,  which  is  also  official,  and  of  which  it 
should  contain  not  less  than  82  per  cent,  by  volume.  The  average 
dose  is  3  min.  (0.2  mil). 

EUGENOL— U.S.P. 

(Eugenol;  C10H12O2.) 

Eugenol  is  an  aromatic  phenol  obtained  from  oil  of  cloves  and 
other  sources.  It  occurs  as  a  thin,  colorless  or  pale  yellow  liquid, 
highly  refractive,  and  possessing  a  strongly  aromatic  odor  of  cloves 
4  nd  a  pungent,  spicy  taste.     It  is  practically  insoluble  in  water,  but 


OLEUM  EUCALYPTI — ^EUCALYPTOL  5 1 

freely  soluble  in  alcohol.  It  may  be  used  instead  of  oil  of  cloves, 
of  which  it  is  the  chief  constituent;  it  is  also  the  chief  constituent  of 
oil  of  pimenta  (allspice).  The  average  dose  is  the  same  as  of  oil  of 
cloves. 

Physiologic  Action. — Oil  of  cloves  is  jiist  sufficiently  irritant  to 
the  animal  cell  to  be  classed  as  an  ideal  antiseptic.  It  also  possesses 
marked  local  analgesic  properties.  Internally  administered,  it  is  a 
powerful  carminative  and  stimulant. 

Therapeutics. — Because  of  its  antiseptic  and  local  analgesic 
properties,  oil  of  cloves  is  one  of  the  most  valuable  volatile  oils.  It 
has  long  been  a  popular  remedy  for  odontalgia  (toothache).  Oil  of 
cloves,  and  its  chief  constituent,  eugenol,  are  excellent  agents  to  be 
employed  as  the  liquid  for  making  pastes  when  pulp-capping  is 
indicated.  A  paste  made  of  precipitated  calcium  phosphate  or 
pure  zinc  oxid,  in  either  of  which  2  per  cent,  of  thymol  has  been  incor- 
porated as  the  powder,  and  oil  of  cloves  or  eugenol  as  the  liquid,  is 
a  valuable  remedy  for  capping  the  pulp,  or  protecting  this  organ 
when  it  is  involved  from  a  deep-seated  carious  cavity.  (See  Practical 
Therapeutics,  p.  312.)  AppHed  to  a  canker  sore  or  in  cases  of 
ulcerative  stomatitis,  oil  of  cloves  will  prove  to  be  one  of  the  best 
healing  agents.  It  is  a  counter-irritant,  and  as  such  will  stimulate 
morbid  processes. 

OLEUM  EUCALYPTI— U.S.P. 

(Oil  of  Eucalyptus.) 

Oil  of  eucalyptus  is  a  colorless,  or  faintly  yellowish  volatile  oil 
distilled  from  the  fresh  leaves  of  Eucalyptus  Globulus,  a  tree  which 
grows  in  the  swampy  regions  of  Australia  and  California.  It  has 
a  characteristic,  aromatic,  somewhat  camphoraceous  odor  and  a 
pungent,  spicy,  and  cooHng  taste.  The  chief  constituent  is  eucalyptol, 
also  official,  and  of  which  it  should  contain  not  less  than  70  per  cent, 
by  volume.     The  average  dose  is  8  min.  (0.5  mil). 

EUCALYPTOL— U.S.P. 

(Eucalyptol;  CioHisO.) 

Eucalyptol  is  a  colorless  liquid,  obtained  from  oil  of  eucalyptus 
and  several  other  volatile  oils,  especially  oil  of  cajuput.  It  is  an 
organic  oxid,  probably  identical  with  cineol,  the  chief  constituent  of 
oil  of  cajuput.  It  has  a  characteristic  and  distinctly  camphoraceous 
odor  and  a  pungent,  spicy,  and  cooling  taste.  Almost  insoluble  in 
water,  freely  soluble  in  alcohol.  The  average  dose  is  5  min.  (0.3 
mil). 


52  ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS 

Physiologic  Action. — ^Locally  applied,  both  oil  of  eucalyptus  and 
eucal}ptol  are  antiseptics,  but  have  an  irritant  action.  Commercial 
oil  of  eucal}^tus  is  so  irritating  that  it  should  not  be  employed  in 
root-canal  treatment.  Many  cases  of  pericementitis  have  been 
produced  by  commercial  oil  of  eucal}^tus  having  been  sealed  in  the 
canals  of  teeth.  Eucalj^Dtol  is  also  irritant,  but  not  nearly  so  irri- 
tant as  commercial  oil  of  eucalj^tus.  When  desired  to  be  used  in 
root-canal  treatment,  eucal^'ptol  should  be  employed,  or  a  refined 
specimen  of  the  oil  which  is  practically  all  eucal}^tol. 

Therapeutics. — Both  oil  of  eucalyptus  and  eucalyptol  have  been 
employed  in  root-canal  treatment.  Like  all  of  the  volatile  oils, 
they  are  practically  worthless  as  remedies  for  correcting  gangrenous 
pulp  conditions,  where  they  have  been  largely  employed  in  the  past. 
While  eucalyptol  is  not  nearly  as  irritant  as  the  oil  of  eucalj^Dtus, 
it  is  still  too  irritant,  unless  modified,  to  be  sealed  in  a  canal  as  an 
antiseptic  remedy  after  the  removal  of  a  Hve  pulp.  Agents,  such 
as  oil  of  cloves  or  eugenol,  having  local  analgesic  as  well  as  antiseptic 
properties,  are  far  preferable.  Oil  of  cajuput,  containing  cineol, 
a  compound  identical  with  eucalyptol,  has  a  solvent  action  on  gutta- 
percha, as  has  also  eucal}ptol,  hence  these  agents  find  their  greatest 
use  in  dental  practice  as  remedies  for  moistening  cavities  to  be 
temporarily  sealed  with  gutta-percha,  or  root-canals  previous  to 
fining  with  gutta-percha.  The  author's  formula  for  a  remedy  to 
be  used  for  this  purpose,  as  well  as  for  sealing  in  the  canals  of  all  teeth 
where  a  mildly  antiseptic  dressing  is  indicated,  is:  Menthol  2  gr. 
(0.14  Gm.),  thjonol  3  gr.  (0.2  Gm.),  eucalyptol  i  dr.  (4.0  mils).  This 
remedy  is  called  eucalyptol  compomid  (modified  eucalyptol) . 

Oil  of  eucal}^tus  is  an  excellent  remedy  in  chronic  inflammation 
of  mucous  membranes,  where  it  can  be  used  as  a  spray  combined 
with  liquid  petroleum  in  the  proportion  of  30-60  min.  to  the  ounce 
(2-4  mils  to  30.0  mils) . 

An  infusion  of  eucalyptus  leaves  (5  per  cent.)  can  be  used  as  a 
mouth-wash  or  gargle  in  stomatitis. 

As  a  stimulant  expectorant  eucalyptus  is  of  great  value  in  colds 
and  chronic  bronchial  catarrh.  A  few  drops  of  the  oil  of  eucalyptus, 
or  eucalyptol,  can  be  dropped  into  hot  water  and  the  steam  inhaled.. 

OLEUM  MENTHA  PIPERIT-S;— U.S.P. 

(Oil  of  Peppermint.) 

Oil  of  peppermint  is  a  colorless,  or  pale  green  volatile  oil,  distilled 
from  the  fresh  or  partly  dried  leaves  and  Uowering  tops  of  Mentha 


MENTHOL  53 

piperita,  having  the  characteristic  strong  odor  of  the  latter  plant  and 
a  strong,  aromatic,  pungent  taste,  followed  by  a  cool  sensation  upon 
inhalation.  Its  chief  constituent  is  menthol,  also  official,  and  of 
which  it  should  yield  not  less  than  50  per  cent.  The  average  dose  is 
3  min.  (0.2  mil).  There  are  two  official  preparations  of  oil  of 
peppermint,  both  of  which  are  useful  in  dental  practice. 

Aqua  Menthae  Piperitae,  Peppermint  Water,  used  as  a  spray, 
as  a  vehicle  for  mouth-washes  and  local  anesthetic  solutions. 
Spiritus  Menthae  Piperitae,  Spirit  of  Peppermint,  is  used  also 
as  a  flavoring  agent. 

3VIENTH0L— U.S.P. 

(Menthol;  C10H20O.) 

Menthol  is  a  stearoptene,  or  secondary  alcohol,  obtained  from 
the  oil  of  peppermint  and  other  mint  oils.  It  occurs  in  colorless, 
acicular,  or  prismatic  crystals,  having  a  strong  and  characteristic 
odor  of  peppermint,  and  a  warm,  aromatic  taste,  followed  by  a 
sensation  of  cold  when  air  is  inhaled.  Sparingly  soluble  in  water, 
freely  in  alcohol,  ether,  and  chloroform.  When  triturated  with 
about  equal  amounts  of  phenol,  thymol,  camphor,  or  chloral  hydrate, 
it  forms  a  liquid.     The  dose  is  i  gr.  (0.06  Gm.). 

Physiologic  Action. — Oil  of  peppermint  and  menthol  are  anti- 
septics, as  well  as  possessing  local  analgesic  properties  to  a  marked 
degree.  Like  many  other  volatile  oils  of  an  aromatic  character, 
oil  of  peppermint  is  a  valuable  carminative,  stimuj^ht,  antifer- 
mentative,  and  antispasmodic. 

Therapeutics. — Oil  of  peppermint,  or  menthol,  is  an  ingredient 
of  many  remedies  for  obtunding  sensitive  dentin.  A  useful  formula 
consists  of  menthol  20  gr.  (1.33  Gm.),  chloroform  2  fl.  dr.  (8.0  mils), 
and  ether  6  fl.  dr.  (24.0  mils).  The  official  water  is  an  excellent 
vehicle  for  local  anesthetic  solutions,  as  well  as  for  mouth-washes 
and  sprays.  Menthol  is  a  constituent  of  many  dental  Hniments 
for  neuralgia  and  pericementitis.  A  good  liniment  for  this  purpose 
contains  menthol  20  gr.  (1.33  Gm.),  chloroform  i3^  fl.  dr.  (6.0  mils), 
and  tincture  of  aconite  6  fl.  dr.  (24.0  mils). 

Oil  of  peppermint,  or  menthol,  is  a  constituent  of  many  lotions 
and  sprays  for  the  local  treatment  of  diseases  of  the  mouth,  ear,  nose, 
and  throat.  Menthol  is  used  extensively  in  headache,  being  rubbed 
on  the  forehead  or  inhaled  from  a  metal  container.  In  cases  of 
itching  of  the  skin  or  mucous  membrane,  menthol  is  a  valuable 
remedy  because  of  its  analgesic  properties.     For  this  purpose  it 


54  ANTISEPTICS,    DISINFECTANTS,    AND   DEODORANTS 

should  be  dissolved  in  a  bland  oil,  like  liquid  petroleum,  in  the 
proportion  of  30  gr.  to  the  ounce  (2.0  Gm.-3o.o  mils).  It  is  also 
a  constituent  of  phenol  compound  (see  below). 

OLEUM  THYMI— U.S.P. 

(Oil  of  Thyme.) 

Oil  of  thyme  is  a  thin,  colorless  or  pale  yellow,  sometimes  red, 
volatile  oil,  distilled  from  Thymus  vulgaris,  a  common  shrub  (garden 
thyme)  which  is  indigenous  to  France,  but  cultivated  in  the  gardens 
of  the  United  States.  It  has  a  strong  odor  of  thyme,  and  a  warm, 
pungent  and,  afterward,  cooling  taste.  Its  chief  constituent  is  thymol, 
which  is  official,  and  of  wliich  the  oil  should  contain  not  less  than  20 
per  cent,  by  volume,  of  phenols.  The  average  dose  is  3  min.  (0.2 
mil). 

THYMOL— U.S.P. 

(Thymol;  C10H14O.) 

Thymol  is  a  phenol  obtained  from  the  oil  of  thyme.  It  occurs  in 
large,  colorless,  translucent  crystals,  having  a^a^^-like  odor  and 
a  pungent,  aromatic  taste,  with  a  slight  cajj^iWnect  upon  the  lips 
and  mucous  membranes.  It  is  sparip^'^soluble  (about  1,100  parts) 
in  water  and  in  less  than  its  o^jja-'^^ght  in  alcohol,  ether,  and  chloro- 
form, also  readily  solub^HliMed  and  volatile  oils.  When  triturated 
with  about  equa^fTl'an titles  of  phenol,  menthol,  camphor,  or  chloral 
hydrate,  it  liquefies. 

Physiologic  Action. — Thymol  is  a  powerful  antiseptic.  It  might 
almost  be  classed  as  a  true  disinfectant.  It  resembles  phenol  in 
its  action,  but  being  slowly  absorbed  is  far  less  poisonous,  yet  vastly 
superior  to  it  as  an  antiseptic.  It  possesses  a  peculiar,  but  favorable 
action  on  animal  tissue.  It  undoubtedly  has  a  preservative  action 
on  dead  animal  tissue.  It  is  a  stimulant  though  not  an  irritant  or 
corrosive,  and  also  has  local  analgesic  properties. 

Therapeutics. — Oil  of  thyme  is  not  much  used  in  dental  practice 
except  as  a  source  from  which  thymol  is  obtained.  Thymol  has  not 
been  used  to  the  extent  which  its  importance  merits,  although  it  is 
rapidly  gaining  favor  with  modern  therapeutists.  It  is  a  constituent 
of  many  remedies  for  root-canal  treatment  after  live  pulps  have  been 
removed.  The  author's  phenol  compound  for  this  purpose  contains 
menthol,  20  gr.  (1.3  Gm.),  thymol,  40  gr.  (2.6  Gm.),  and  phenol 
(U.S.P.)  3  dr.  (12.0  mils).  In  order  to  make  the  remedy  less 
irritating,  camphor  has  been  substituted  for  the  thymol  in  the  latter 


lODUM — lODOFORMUM  55 

formula.  Dr.  E.  C.  Kirk  suggests  using  equal  parts  of  thymol  and 
phenol,  called  thymophen.  Dr.  H.  Prinz  uses  th3miol,  camphor  and 
phenol,  called  thymocamphen.  A  solution  of  a  grain  (0.06  Gm.) 
to  the  ounce  of  water  (30.0  mils),  with  a  Httle  alcohol  used  as  a 
solvent,  makes  a  good  mouth-wash  in  the  infectious  forms  of 
stomatitis  and  pharyngitis  (Stevens).  It  is  a  constituent  of  the 
formerly  official  mouth-wash,  Hquor  antisepticus  (see  p.  43);  also 
the  author's  Desensitizing  Paste  (see  p.  293). 

lODUM— U.S.P. 

(lodin;  I.) 

lodin  is  a  nonmetallic  element  obtained  chiefly  from  the  ashes 
of  sea- weeds  (kelp) .  Fine  specimens  of  such  sea- weeds  may  be  seen 
in  the  "submarine  gardens"  around  Catalina  Island,  off  the  shore 
of  Southern  Cahfornia.  It  occurs  in  heavy,  bluish-black,  friable 
crystals,  having  a  metaUic  luster,  a  distinctive  odor,  and  a  sharp, 
acrid  taste.  On  heating,  it  emits  a  violet-colored  vapor.  lodin  is 
sparingly  soluble  in  water  (5,000  parts),  quite  soluble  in  a  solution 
of  potassium  iodid,  and  freely  so  in  alcohol,  ether,  and  chloroform. 
The  average  dose  is  3^2  gr.  (0.005  Gm.). 

The  three  official  preparations  are  of  value  in  dental  practice. 
They  are: 

Liquor  lodi  Compositus,  U.S.P.  Compound  Solution  of 
lodin  (Lugol's  Solution;  5  per  cent,  of  lodin  in  a  10  per  cent, 
solution  of  Potassium  Iodid). 

Tinctura  lodi,  U.S.P.,  Tincture  of  lodin  (7  per  cent.). 
Unguentum  lodi,  U.S.P.,  lodin  Ointment  (4  per  cent.). 

lODOFORMUM— U.S.P. 

(Iodoform;  CHI3.) 

Iodoform  is  methyl  tri-iodid,  made  by  heating  in  a  closed  vessel 
iodin,  alcohol,  sodium  hydrate,  and  water,  wherein  3  atoms  of  hydro- 
gen of  the  methane  radicle  (CH4)  are  displaced  by  3  of  iodin.  It 
occurs  in  small,  lemon-yellow,  hexagonal  crystals,  having  a  pecuHar, 
very  penetrating,  and  persistent  odor,  and  an  unpleasant,  slightly 
sweetish,  and  iodin-Kke  taste.  It  is  very  feebly  soluble  in  water, 
soluble  in  about  60  parts  of  alcohol  at  25°C.  and  freely  soluble  in 
ether,  chloroform,  and  oils.  It  contains  about  96  per  cent,  of  iodin. 
The  average  dose  is  4  gr.  (0.25  Gm.).  The  official  ointment  of  iodo- 
form contains  10  per  cent. 


56  ANTISEPTICS,   DISINFECTANTS,   AND   DEODORANTS 

lODOLUM  (Nonofficial) 
(lodol;  Tetra-iodo-pyrrol;  C4I4NH.) 

lodol,  or  tetra-iodo-pyrrol,  is  a  derivative  of  the  base  pyrrol 
(C4H6N),  obtained  by  the  direct  action  of  iodin  upon  the  base  in 
the  presence  of  alcohol.  It  occurs  as  a  yellowish,  crystalline  pow- 
der, without  odor  or  taste,  and  contains  about  90  per  cent,  of  iodin. 
lodol  is  practically  insoluble  in  water,  but  freely  soluble  in  alcohol, 
ether,  and  oils.  It  is  used  as  a  substitute  for  iodoform,  and,  though 
more  expensive,  has  the  decided  advantage  of  being  odorless. 

THYMOLIS  lODIDUM— U.S.P. 

(Thymol  lodid;  Di-thymol-di-iodid ;  Aristol;  C2oH2402l2.) 

Thymol  iodid  or  aristol,  is  obtained  by  acting  upon  thymol  in 
aqueous  solution  of  sodium  hydrate  with  iodin  dissolved  in  a  solution 
of  potassium  iodid.  It  occurs  as  a  brownish-red  powder,  tasteless 
and  almost  odorless,  and  contains  about  43  per  cent,  of  iodin.  It 
is  nearly  insoluble  in  water,  but  freely  soluble  in  ether,  chloroform, 
and  oils.  It  is  used  as  a  substitute  for  iodoform,  but  is  rather  un- 
stable, being  decomposed  by  heat,  light,  acids,  alkahes,  alcohol,  and 
corrosive  sublimate.  It  is  more  expensive  than  iodoform  and  less 
effective. 

EUROPHEN  (Nonofficial) 
(Di-isobutyl-cresol-iodid;  C22H29O2I:) 

Etirophen  is  obtained  in  exactly  the  same  manner  as  that  of  pre- 
paring aristol,  except  that  isobutyl-cresol  is  substituted  for  thymol. 
It  occurs  as  a  very  bulky,  yellow,  amorphous  powder,  of  an  aro- 
matic odor,  and  contains  28  per  cent,  of  iodin.  It  is  insoluble  in 
water  and  glycerin,  but  freely  soluble  in  alcohol,  ether,  and  oils.  In 
dental  practice  it  is  an  excellent  substitute  for  iodoform,  and  is  far 
more  stable  than  aristol. 

NOSOPHEN  (Nonofficial) 
(Tetra-iodo-phenol-phthalein ;   (C6H2I2OH)  2C8H4O2.) 

Nosophen  is  obtained  by  the  action  of  iodin  on  a  solution  of 
phenol-phthalein.  It  is  a  pale  yellow  powder,  without  odor  and 
taste,  and  contains  60  per  cent,  of  iodin.  It  differs  from  iodoform  in 
being  an  active  antiseptic  and  in  not  3aelding  its  iodin  to  the  tissues. 


NOSOPHEN  57 

Physiologic  Actions. — lodin  can  be  classed  as  an  ideal  anti- 
septic in  that  it  is  just  sufficiently  irritant  to  the  animal  cell  to  cause 
stimulation,  giving  to  the  latter  new  life  and  energy  whereby  the  ani- 
mal cells  attack  and  kill  the  invading  germ,  thus  producing  nature's 
method  of  disinfection. 

When  applied  to  the  skin  or  mucous  membrane  it  produces  a 
yellowish-brown  or  black  evanescent  stain,  and  acts  as  an  irritant  or 
caustic,  according  to  the  strength  of  the  solution  used,  and  the  fre- 
quency of  the  application.  This  discoloration  can  be  readily  re- 
moved by  solutions  of  potassium  cyanid,  sodium  hj^osulphite  or 
ammonia.  When  tincture  of  iodin  is  frequently  applied,  vesication 
is  produced,  or  perhaps  sloughing.  The  blood-vessels  subjacent  to 
the  area  to  which  it  is  applied  are  reflexly  dilated,  hence  this  drug  is  an 
efficient  counterirritant. 

When  internally  administered,  it  is  rapidly  absorbed  in  the  form 
of  iodids  and  soon  reappears  in  all  the  secretions  of  the  body;  the 
bulk  being  eliminated,  however,  in  the  urine,  also  in  the  form  of 
iodids.  The  continuous  use  is  followed  by  a  group  of  symptoms 
known  as  iodism.  The  more  common  manifestations  of  this  condi- 
tion are  associated  with  the  mucous  membrane  of  the  respiratory 
tract  and  with  the  skin,  consisting  of  froatal  headache,  lacrimation, 
coryza,  soreness  of  the  throat,  an  increased  flow  of  saHva,  and  some- 
times an  eruption  on  the  skin.  The  amount  of  the  drug  required  to 
produce  iodism  varies  with  different  individuals.  Iodoform  differs 
somewhat  in  its  action  from  iodin.  Instead  of  being  an  irritant,  it 
acts  as  a  mild  analgesic  when  applied  to  the  mucous  membrane  and 
abraded  surfaces,  especially  the  latter.  Iodoform  and  allied  com- 
pounds have  a  favorable  action  on  infected  wounds,  but  how  the 
result  is  produced  is  not  well  understood.  It  is  known  that  as  dry 
powders  they  possess  little  or  no  bactericidal  action,  yet  when  applied 
to  raw  surfaces  they  retard  germ-growth,  probably  through  the  free 
iodin  liberated,  as  they  nearly  all  Hberate  their  contained  iodin  when 
in  contact  with  the  fluids  of  the  tissues. 

Therapeutics. — Applied  to  infected  wounds,  iodin  is  an  efficient 
antiseptic.  The  tincture  of  iodin  or  the  compound  solution  may  be 
employed  in  full  strength,  or  diluted,  to  sluggish  ulcers  and  abscess 
cavities,  or  in  cases  of  local  arsenical  poisoning.  For  the  latter  condi- 
tion, a  creamy  paste  made  of  europhen  and  liquid  petroleum  can  be 
appKed  to  the  affected  part  on  sterile  gauze  or  cotton.  Where  pain  is 
a  prominent  symptom,  as  in  cases  of  lacerated  gum  tissue  and  exposed 
process  after  extraction,  othoform  (40  parts)  can  be  mixed  with  euro- 
phen (60  parts)  and  made  into  a  paste  with  Hquid  petroleum.     Ap- 


58  ANTISEPTICS,    DISINFECTANTS,    AND   DEODORANTS 

plied  in  the  same  manner  it  will  stop  the  pain  Hke  magic.  This  remedy 
is  called  euroform  paste.  As  a  counterirritant  iodin  is  a  valuable 
drug,  as  the  blood-vessels  subjacent  to  the  area  to  -which  it  is  applied 
are  reflexly  dilated.  The  tincture  of  iodin  in  full  strength  should  not 
be  used  as  a  dental  counterirritant  because  of  its  local  destructive 
action  on  the  mucous  membrane.  For  this  purpose  the  compound 
solution  should  be  employed  or  the  tincture  of  iodin  modified.  A 
favorite  combination  is  tincture  of  aconite  2  parts,  tincture  of  iodin 
and  chloroform,  of  each,  i  part.  The  chloroform  volatilizes  rapidly 
when  applied  and  the  irritant  action  of  the  iodin  is  modified  by  the 
aconite,  a  local  sedative.  This  remedy  is  especially  valuable  in  cases 
of  pericementitis,  where  a  mild  but  persistent  counterirritant  effect 
is  desired.  It  is  also  used  to  steriHze  the  mucous  membrane  before 
injecting  local  anesthetic  solutions. 

Iodin  will  stain  the  tooth-structure  and  there  is  no  necessity 
for  using  the  drug  within  the  tooth,  as  other  remedies  are  at  hand 
which  will  .accomplish  all  that  can  be  expected  of  iodin  without 
discoloration. 

Iodin  is  useful  as  an  antiseptic  and  stimulant  in  the  treatment  of 
pyorrhea  alveolaris  and  will  be  referred  to  again  in  Practical  Therapeu- 
tics (p.  435).  Iodoform  has  little  use  in  dental  therapeutics  except 
iodoform  gauze,  which  is  used  in  packing  surgical  wounds,  abscess 
cavities,  etc. 

BETANAPHTHOL— U.S.P. 

(B  etanaphthol ;  C10H7OH.) 

Betanaphthol  is  a  monatomic  phenol  occurring  in  coal-tar,  but 
usually  prepared  artificially  from  naphthalene.  It  occurs  in  white, 
shining  crystalline  scales,  or  as  a  yellowish-white  crystaUine  powder, 
having  a  faint,  phenol-like  odor  and  a  sharp,  pungent,  but  not  per- 
sistent taste.  It  is  sparingly  soluble  in  water,  freely  in  alcohol,  ether, 
and  chloroform.  It  should  be  kept  in  dark,  amber-colored,  well- 
stoppered  bottles.     The  average  dose  is  4  gr.  (0.25  Gm.). 

Physiologic  Action. — Betanaphthol  is  antiseptic,  antifermenta- 
tive,  deodorant,  and  may  also  be  considered  a  disinfectant.  Its 
action  closely  resembles  that  of  phenol,  but  is  less  poisonous. 

When  appHed  locally  to  the  skin  or  mucous  membrane,  betanaph- 
thol is  readily  absorbed,  and,  in  concentrated  solutions,  it  is  irritating 
to  the  tissues  to  which  it  is  appHed.  Toxic  symptoms  may  result 
from  its  absorption  by  the  skin;  these  also  resemble  those  of  phenol. 

Therapeutics. — Betanaphthol  has  been  recommended  as  a  con- 
stituent of  root-canal  filHng  materials.     It  will  not  corrode  metal 


EESORCmOL  59 

instruments,  therefore  solutions  can  be  used  for  immersing  instru- 
ments during  the  surgical  treatment  of  pyorrhea  and  other  opera- 
tions. The  solubiUty  of  the  drug  is  increased  in  boiling  water.  A 
suitable  solution  can  be  prepared  in  hot  water  and  used  when  suffi- 
ciently cooled.  Some  of  the  drug  will  be  precipitated  as  the  solu- 
tion cools,  but  as  it  is  not  irritating  in  this  strength  solution  it 
does  not  matter  materially.  The  saturated  aqueous  solution  may 
also  be  employed  to  irrigate  wounds  and  as  a  constituent  of 
mouth-washes. 

In  medicine  it  is  used  as  a  parasiticide  in  certain  diseases  of  the 
skin,  as  scabies  (itch)  and  ring-worm.  It  is  best  to  employ  it  in  the 
form  of  an  ointment  in  the  strength  of  a  dram  (4.0  Gm.)  to  the  ounce 
(30.0  Gm.),  for  in  this  way  it  is  not  irritating. 


RESORCmOL— U.S.P. 

(Resorcin;  C6H4(OH)2.) 

Resorcin  is  a  diatomic  phenol  occurring  in  the  form  of  colorless 
or  faintly  reddish,  needle-shaped  crystals,  or  rhombic  plates,  having 
a  faint  peculiar  odor  and  a  sweetish,  and  afterward  pungent  taste. 
It  is  freely  soluble  in  water,  alcohol,  ether,  and  glycerin.  It  darkens 
when  exposed  to  light  and  air,  and  should  be  kept  in  dark  amber- 
colored,  well-stoppered  bottles.    The  average  dose  is  2  gr.  (o.i  25  Gm.) . 

Physiologic  Action. — Resorcin  acts  very  much  Uke  phenol, 
but  is  less  poisonous  and  less  irritant.  It  has  marked  antiseptic 
properties,  and  being  practically  nonirritating  is  a  useful  drug  in 
the  treatment  of  many  pathologic  conditions  about  the  mouth  and 
throat. 

Therapeutics. — Resorcin  has  been  used  for  keeping  instruments 
sterile  during  surgical  operations,  but  its  continued  use  will  affect 
the  metal.  In  a  2  to  5  per  cent,  solution  it  is  efficacious  as  a  mouth- 
wash or  gargle  in  the  treatment  of  certain  subacute  and  chronic  con- 
ditions of  the  mucous  membrane,  as  in  ulcerative  stomatitis,  pharyn- 
gitis, laryngitis,  whooping-cough,  and  diphtheria.  An  ointment  of 
resorcin  (5  per  cent.)  is  an  excellent  remedy  to  apply  to  sloughing 
wounds,  foul  ulcers,  and  syphilitic  ulcers.  A  dusting  powder,  con- 
sisting of  I  part  resorcin  and  10  parts  boric  acid,  can  be  used  with 
much  benefit  in  cases  of  suppurating  wounds.  As  a  remedy  for 
dandruff  of  the  scalp,  Stevens  recommends  the  following:  Resorcin 
i}4  dr.  (6.0  Gm.),  castor  oil  TH,  xx-xxx  (1.2-2.0  mils),  bay-rum  33^^ 
fl.  oz.  (105.0  mils). 


6o  ANTISEPTICS,    DISINFECTANTS,    AND   DEODORANTS 

CARBO  LIGNI— U.S.P. 

Carbon  was  formerly  official  in  the  following  forms:  Animal 
charcoal,  purified  animal  charcoal,  and  wood  charcoal.  The  latter  is 
the  only  form  recognized  in  the  U.S. P.  IX.  Animal  charcoal,  or 
bone-black,  is  prepared  by  burning  bones  in  closed  iron  cylinders. 
It  is  composed  of  carbon  and  certain  earthy  salts  (calcium  carbonate 
and  phosphate) .  Purified  animal  charcoal  is  bone-black  from  which 
the  above-mentioned  salts  have  been  removed  by  hydrochloric 
acid.  Wood  charcoal  is  prepared  by  burning  soft  wood  without 
access  to  air;  it  is  very  finely  powdered.  It  occurs  as  a  black, 
odorless  and  tasteless  powder,  free  from  gritty  matter. 

Charcoal  is  mentioned  here  because  of  its  deodorizing  power.  It 
has  the  peculiar  property  of  absorbing  many  times  its  own  volume 
of  gases  and  vapors.  It  is  not  used  much  in  dental  practice,  except 
in  the  laboratory  for  refining  metals.  When  well  ignited  it  will 
deoxidize  the  most  obdurate  metals.  Animal  charcoal  is  largely  used 
by  chemists  for  decolorizing  many  solutions  and  for  removing  color- 
ing matter  from  alkaloids.  It  is  also  employed  as  a  filtering  medium 
for  purifying  drinking-water.  White  wood  ash  was  formerly  used 
for  cleaning  teeth  by  the  laity.  Because  of  the  grittiness  of 
the  particles,  it  should  not  be  so  employed.  It  is  sometimes  in- 
ternally given  as  an  absorbent  in  flatulent  dyspepsia.  Here  it  is 
best  administered  in  the  form  of  lozenges. 

CALENDULA  (Nonofficial) 
(Marigold.)     . 

Calendula  is  the  dried  ligulate  florets  of  Calendula  officinalis,  an 
annual  plant,  indigenous  to  Southern  Europe  and  the  Levant,  fre- 
quently cultivated  as  a  garden  ornament.  It  contains  a  bitter 
principle,  calendulin,  and  a  trace  of  volatile  oil.  The  average  dose 
is  5  gr.  (0.3  Gm.).     The  tincture  is  the  only  preparation  employed: 

Tinctura  Calendulas,  U.S. P.  VIII  (20  per  cent.).     Dose,  15 
min.  (i.o  mil). 

Physiologic  Action  and  Therapeutics. — Calendula  has  a  stimu- 
lating action  upon  mucous  membranes,  and  has  been  used  chiefly  for 
its  local  influence.  It  acts  similar  to  arnica,  and  is  employed  for 
practically  the  same  conditions.  The  tincture  may  be  applied  to 
recent  wounds,  lacerated  gums,  open  sores,  etc.  It  hastens  the  heaHng 
of  wounds,  and  materially  aids  union  of  coapted  surfaces  by  first 
intention.  It  causes  a  scar,  or  cicatrix,  to  form  without  contraction 
of  tissue,  and  is  especially  useful  in  severe  hums. 


AENICA — OXYGENIUM  6 1 

ARNICA— U.S.P. 

Arnica  is  the  dried  flower-heads  of  Arnica  montana,  a  perennial 
plant/  growing  in  temperate  regions  of  Europe,  Asia,  and  America. 
It  contains  a  glucosid,  arnicin,  and  a  volatile  oil.     The  dose  is  about 
15  gr.  (i.o  Gm.).     The  tincture  is  the  only  ofl&cial  preparation: 
Tinctura  Arnicae,  U.S.P.     Average  dose,  15  min.  (i.o  mil). 

Physiologic  Action  and  Therapeutics. — The  action  of  arnica 
closely  resembles  that  of  calendula.  The  tincture  has  been  exten- 
sively used  as  a  stimulating  application  in  sprains  and  bruises.  Its 
antiseptic  power  is  doubtless  due  to  its  irritant  effect  upon  animal 
cells,  and  to  the  alcohol  which  the  tincture  contains. 

MYRRHA— U.S.P. 

(Myrrh.) 

Myrrh  is  a  gum-resin  obtained  from  commiphora  myrrha,  a  small 
tree  growing  in  Eastern  Africa  and  Arabia.  It  occurs  in  the  form  of 
brownish-red,  irregularly-shaped  tears,  having  an  agreeable  aromatic 
odor  and  a  bitter,  acrid  taste.  The  dose  is  about  5  gr.  (0.3  Gm.). 
Its  official  preparations  and  those  into  which  it  enters  are : 

Tinctura  Myrrhae,  U.S.P.  Average  dose,  15  min.  (1.0  mil). 
Pilulae  Rhei  Compositse,  U.S.P.  (Aloes,  ^  gr.  o.i  Gm.; 
Rhubarb  2  gr .-0.13  Gm.;  Myrrh,  I  gr.-o.o6  Gm.).  Average 
dose,  2  pills. 

Physiologic  Action  and  Therapeutics. — Myrrh  is  a  stimulant 
to  mucous  membranes  and  acts  as  an  antiseptic  and  astringent.  The 
tincture,'  diluted  with  water  or  with  a  weak  solution  of  borax  or 
potassium  chlorate,  has  been  extensively  used  as  a  local  application 
in  ptyalism,  ulcerative  stomatitis,  and  spongy  gums.  Water  added  to 
the  tincture  causes  a  milky  solution  on  account  of  the  resinous 
constituent  of  myrrh. 

OXYGENIUM— U.S.P. 

(Oxygen;  O.) 

Oxygen,  for  the  first  time,  is  recognized  by  the  U.S.P.  It  is  a 
colorless,  odorless  and  tasteless  gas;  practically  insoluble  in  water, 
more  readily  soluble  in  alcohol.  It  contains  not  less  than  95  per 
cent,  by  volume  of  O  (16) ;  and,  for  convenience,  it  is  usually  com- 
pressed in  metal  cyHnders.  The  U.S.P.  IX  has  adopted  oxygen 
(16)  as  the  standard  for  atomic  weights,  in  accordance  with  the  report 
of  the  International  Committee  on  Atomic  Weights  for  1915. 
Formerly  hydrogen  (i.oi)  was  taken  as  the  standard.     Oxygen  is 


62  ANTISEPTICS,    DISINFECTANTS,    AND    DEODORANTS 

correct  as  it  weighs  exactly  i6,  while  hydrogen  was  only  approxi- 
mately correct  since  it  weighs  i.oi.  The  gas  is  used  extensively  in 
nitrous  oxid,  ether  and  chloroform  narcosis,  as  well"  as  in  bronchitis, 
anemia,  phthisis,  and  the  later  stages  of  acute  pneumonia.  It  is  given 
by  inhalation  by  means  of  a  specially  devised  apparatus.  It  is  also 
used  in  dentistry  as  a  bleaching  agent  (see  Practical  Therapeutics 
p.  404).  For  bleaching  purposes  the  oxygen  is  obtained  from  com- 
pounds containing  it,  such  as  sodium  dioxid  and  hydrogen  dioxid. 
For  experimental  purposes,  it  may  be  obtained  by  carefully  heating 
potassium  chlorate  in  a  suitable  retort.  If  the  potassium  chlorate 
be  previously  mixed  with  about  one-fourth  of  its  weight  of  man- 
ganese dioxid,  it  gives  up  the  whole  of  its  oxygen  at  a  temperature 
considerably  below  the  melting-point  of  the  salt,  and  at  a  greatly 
accelerated  rate. 

Ozone  is  an  allotropic  form  of  oxygen,  and  may  be  prepared  from 
the  latter  electrically.  It  occurs  in  the  air,  especially  after  an  elec- 
trical storm.  It  is  no  doubt  an  important  factor  in  the  antiseptic 
processes  of  nature,  and  has  been  used  to  some  extent  as  a  thera- 
peutic agent  in  the  treatment  of  pyorrhea  alveolaris,  and  other  patho- 
logic conditions;  but  its  practical  application,  as  yet,  has  not  been 
fully  demonstrated. 

PHENOL— U.S.P. 

(Phenol;  Carbolic  Acid;  CeHgOH.) 

Phenol  is  obtained  from  coal-tar  by  fractional  distillation.  It 
is  also  prepared  synthetically.  When  pure,  it  occurs  in  the  form  of 
colorless,  needle-shaped  crystals,  of  a  characteristic  odor  and  of  an 
acrid,  burning  taste.  On  exposure  to  damp  air  it  deliquesces,  and 
the  solution  exposed  to  light  gradually  acquires  a  reddish  tint.  It 
is  soluble  in  about  15  parts  of  water,  at  2  5°C.,  and  freely  in  alcohol, 
glycerin,  ether,  chloroform,  and  oils.  It  should  be  kept  in  dark 
amber-colored  bottles,  well-stoppered.  Although  it  was  official 
up  to  1900  under  the  name  Acidum  Carbolicum,  chemically  con- 
sidered, it  is  not  an  acid,  but  an  alcohol  of  the  benzene  group. 
The  average  dose  is  i  gr.  (0.06  Gm.). 

All  of  the  official  preparations  are  valuable  in  dental  practice. 
They  are:  y 

Phenol  Liquef actum,  U.S. P.   (contains  86.4  per  cent,  of 

absolute  Phenol  and  13.6  per  cent,  of  Water). 

Unguentum  Phenolis,  U.S. P.     Ointment  of  Phenol  (2^ 

per  cent.). 

Glyceritum  Phenolis,  U.S. P.     Glycerite  of  Phenol  (20  per 

cent.). 


PHENOL  63 

Physiologic  Action. — Phenol  is  a  disinfectant,  as  it  destroys 
microorganisms.  Some  spore-bearing  forms,  however,  are  very 
resistant  to  its  action.  In  weak  solutions  (2  per  cent.)  it  acts  as  an 
antiseptic.  Phenol  is  also  a  caustic  and  local  analgesic.  When 
apphed  to  the  skin  or  mucous  membrane  it  blanches  the  surface  and 
causes  a  burning  sensation,  which  is  soon  followed  by  numbness. 
Later  the  part  becomes  red,  then  brown,  and  ultimately  desquamation 
takes  place.  Its  action  is  much  more  severe  on  mucous  membranes, 
and  it  should  be  used  about  the  mouth  with  caution.  Phenol  coagu- 
lates albumin,  therefore  its  caustic  action  is  limited,  and  does  not 
extend  deeply  into  the  tissues.  Absorption  of  the  drug  occurs  readily 
from  the  skin,  mucous  membranes,  and  wounds.  Its  prolonged 
use,  even  in  dilute  solutions  (2-5  per  cent.)  may  cause  gangrene  of 
the  parts. 

Poisoning  by  Phenol. — Poisoning  by  phenol  may  occur  either 
from  the  drug  being  taken  internally  or  from  its  external  appli- 
cation. It  is  a  poison  used  more  widely  for  suicidal  purposes,  per- 
haps, than  any  other.  Because  of  this  fact,  a  law  is  in  force  in  many 
States  of  the  Union  preventing  its  sale  to  the  laity  in  stronger 
solutions  than  333^  per  cent,  the  dilution  being  made  with  alcohol  or 
glycerin. 

Toxic  doses  render  the  patient  rapidly  unconscious,  or  the  patient 
may  drop  dead  in  from  twelve  to  fifteen  minutes  after  taking  it  from 
respiratory  paralysis.  Butler  states  that  8.5  Gm.  have  caused  the 
death  of  an  adult  in  fifteen  minutes.  One  and  one-half  grams  have 
caused  the  death  of  a  child  in  a  short  time.  If  the  dose  has  not  been 
sufficient  to  cause  respiratory  paralysis  in  so  short  a  time,  the  symp- 
toms are  those  of  gastroenteritis — intense  pain,  violent  vomiting  of 
white  slimy  mucus,  and  purging.  The  pupils  are  contracted,  sterto- 
rous breathing  appears,  with  cold,  clammy  skin,  pinched  face,  anxious 
expression,  and  a  rapid,  feeble  pulse,  finally  followed  by  unconscious- 
ness and  death  from  failure  of  respiration.  The  characteristic  phe- 
nomena are  the  odor  on  the  breath,  the  destruction  of  the  buccal 
mucous  membrane,  and  the  smoky  urine.  In  poisoning  from  the 
external  use  of  phenol  the  initial  symptoms  generally  are  headache, 
vertigo,  pallor,  muscular  weakness,  and  discoloration  of  the  urine. 

Treatment  of  Poisoning. — When  the  poison  has  been  taken  by 
the  mouth  there  are  two  drugs  especially  indicated  in  the  treatment 
— alcohol  and  magnesium  sulphate  (Epsom  salt).  The  alcohol  neu- 
trahzes  the  caustic  action,  and  the  soluble  sulphate  forms  with  the 
phenol  the  innocuous  phenol  sulphonate.  Two  or  three  ounces  (60.0 
-90.0  mils)  of  diluted  alcohol  should  be  poured  into  the  stomach 


64  ANTISEPTICS,   DISINFECTANTS,   AND   DEODORANTS 

through  a  tube,  followed  by  frequent  washing  out  of  the  stomach  with 
warm  water  containing  magnesium  sulphate.  Warm  demulcent 
drinks  are  useful  in  allaying  the  irritation.  To  increase  the  efficiency 
of  the  function  of  the  heart  and  respiration,  strychnin  sulphate  and 
atropin  sulphate  are  indicated.  For  the  relief  of  pain,  opium  or  its 
alkaloids  may  be  administered.  When  phenol  is  accidentally  or 
otherwise  appUed  to  the  skin  or  mucous  membrane,  its  caustic  action 
can  be  prevented  by  immediately  appl5dng  alcohol  to  the  part. 

Therapeutics. — Phenol,  possessing  as  it  does  the  properties  of 
an  antiseptic,  disinfectant,  cauterant,  and  local  analgesic,  is  one  of 
the  most  useful  drugs  in  dental  practice.  As  a  disinfectant,  the  true 
value  of  the  drug  has  been  overestimated.  Its  great  affinity  for  al- 
bumin, which  it  quickly  and  firmly  coagulates,  prevents  any  penetra- 
tion beyond  the  superficial  layer  of  tissue  to  which  it  is  applied.  At 
best,  then,  it  is  but  a  surface  disinfectant.  A  i  per  cent,  solution  can 
be  employed  for  immersing  the  points  of  instruments  while  scaling 
the  teeth  in  pyorrheal  treatment.  Probably  the  only  objection  to  this 
solution  is  the  odor,  and  yet  patients  have  been  taught  that  any  solu- 
tion possessing  the  odor  of  phenol  is  cleansing,  so  even  this  objection 
loses  its  weight. 

The  drug  can  be  added  to  local  anesthetic  solutions  for  the  purpose 
of  keeping  the  latter  sterile.  Two  to  3  gr.  (0.13-0.19  Gm.)  to  the 
ounce  (30.0  mils)  is  sufficient  to  prevent  the  growth  of  bacteria,  and 
in  this  strength  it  can  be  injected  into  the  tissue  without  any  appreci- 
able coagulation  of  the  albumin. 

Its  local  analgesic  property  makes  it  a  valuable  remedy  for  desen- 
sitizing dentin,  to  apply  to  an  aching  pulp  in  the  early  stages  of 
pulpitis,  and  also  as  a  root-canal  dressing  after  the  removal  of  the 
pulp  tissue  by  either  the  anesthetization  or  devitalization  method. 
It  has  been  used  for  devitalizing  the  pulp  tissue  in  deciduous  teeth. 
Its  action  here  is  slow  and  unsatisfactory.  As  a  stimulating  agent  for 
cauterizing  sinuses  associated  with  dento-alveolar  abscesses,  it  has  long 
been  used  with  success  where  there  is  no  root  or  bone  compUcation. 
In  cases  of  painful  canker  sores  it  is  a  most  useful  remedy.  Applied 
full  strength  to  the  ulcerated  or  denuded  spot,  it  arrests  the  septic 
process,  and  the  coagulum  formed  serves  as  a  protection  to  the 
exposed  nerve-endings. 

CRESOL— U.S.P. 

.CH3\ 
(Cresol;  Tricresol;  C6H4('        .  I 

OH/ 


CRESOL  65 

Cresol,  formerly  commercially  called  tricresol,  is  a  refined  mixture 
of  three  isomeric  cresols  obtained  from  coal-tar,  freed  from  phenol, 
hydrocarbons,  and  water.  It  occurs  as  a  colorless  or  straw-colored 
refractive  liquid,  having  a  phenol-Hke  odor  and  a  burning,  caustic 
taste.  It  is  soluble  in  50  parts  of  water  at  2  5°C.,  and  miscible  with 
alcohol  and  glycerin  in  all  propotions.  Cresol  is  sometimes  errone- 
ously called  crecyHc  acid.  It  is  not  an  acid,  but  is  methyl  phenol, 
the  three  isomeric  forms  being  known  chemically  as  ortho-,  meta-,  and 
paracresol.  On  exposure  to  hght,  cresol  turns  to  a  yellowish-brown 
color.  It  should  be  kept  in  dark  amber-colored  bottles,  well-stop- 
pered. The  dose  is  i  minim  (0.06  mil.).  The  official  Liquor 
Cresolis  Compositus  (Compound  Solution  of  Cresol)  is  practically 
identical  with  the  commercial  preparation  known  as  lysol.  It  is  a 
linseed-oil-soap  solution  of  cresol,  50  per  cent,  in  strength. 

Lysol  (nonofficial)  is  a  cresol  preparation  made  by  dissolving  in 
fat,  and  subsequently  saponifying  with  alcohol  that  portion  of  tar-oil 
which  boils  between  347°  and  392°F.  (190°  and  2oo°C.).  It  con- 
tains 50  per  cent,  of  comparatively  pure  cresols.  It  is  a  brown,  oily 
liquid,  and  mixes  with  water  to  form  a  clear,  saponaceous,  frothy 
liquid. 

Physiologic  Action. — Cresol  is  one  of  the  newer  preparations, 
and  its  action  is  almost  identical  with  that  of  phenol.  Some  authorities 
claim,  however,  that  cresol  is  more  toxic  to  bacteria  than  is  phenol, 
but  that  it  is  less  toxic  to  the  animal  cell  than  is  the  latter.  In  this 
respect  it  approaches  what  might  be  termed  an  ideal  disinfectant — an 
agent  which  will  kill  the  bacteria  without  acting  deleteriously  upon 
the  animal  cell;  but  cresol  is  too  toxic  to  the  animal  cell  to  be  so  consid- 
ered. Cresol  is  a  caustic,  though  somewhat  milder  in  action  than 
phenol,  and  it  possesses  marked  local  analgesic  properties. 

Therapeutics. — Cresol  is  a  disinfectant.  It  may  be  used  in 
dental  practice  with  equal  results  in  almost  every  condition  where 
phenol  is  indicated.  In  some  instances  it  is  greatly  superior  to  the 
latter  drug.  Its  odor  maybe  considered  an  objection,  but  its  valuable 
properties  far  outweigh  this  slight  objection.  As  a  local  analgesic 
or  anodyne  for  root-canal  dressings  it  is  valuable,  and  can  be  used 
with  success  as  a  cauterizing  and  stimulating  agent  in  uncomplicated 
sinuses  associated  with  dento-alveolar  abscesses.  It  can  be  dissolved 
in  glycerin  or  alcohol,  with  both  of  which  it  is  miscible  in  all  propor- 
tions, and  the  solution  added  to  mouth-washes,  sprays,  and  other 
antiseptic  remedies.  A  i :  500  solution  may  be  used  as  a  vehicle  in 
which  to  dissolve  local  anesthetic  agents,  as  cocain  hydrochlorid. 
Such  solutions  remain  free  from  bacteria,  and  are  not  irritant  to  the 


66  ANTISEPTICS,    DISIXFECTAXTS,    AXD    DEODORANTS 

tissues  in  which  they  are  injected.  It  is  a  constituent  of  the  author's 
formocresol  remedy  which  is  an  absolute  specific  for  gangrenous  pulp 
conditions. 

The  compound  solution  of  cresol  and  lysol  is  used  in  from  i  to  2 
per  cent,  solutions  in  surgical  work,  as  in  the  treatment  of  pyorrhea. 

CREOSOTUM— U.S.P. 

(Creosote.) 

Creosote  is  a  mixture  of  phenols  and  phenol  derivatives,  chiefly 
guaiacol  and  creosol,  obtained  during  the  distillation  of  wood-tar, 
preferably  of  that  derived  from  the  beech.  It  is  an  almost  colorless, 
or  a  faintly  yellow,  oily  liquid,  having  a  penetrating,  smoky  odor,  and 
a  burning,  caustic  taste.  It  is  sHghtly  soluble  in  water,  soluble  in 
all  proportions  in  alcohol,  ether,  chloroform,  and  oils.  It  seems 
rather  dif&cult  to  obtain  pure  beech-wood  creosote.  Much  of  the 
creosote  on  the  market  is  impure  phenol  (carbolic  acid).  Tests  for 
the  purity  of  the  drug  can  be  made  as  follows:  i.  Mix  equal  quan- 
tities of  the  suspected  specimen  and  collodion  in  a  clean,  dry  test- 
tube;  the  formation  of  a  coagulum  wiU  indicate  the  presence  of  phenol. 
2.  Mix  intimately  equal  volumes  of  the  suspected  liquid  and 
glycerin,  then  add  one  or  more  volumes  of  water;  the  absence  of  tur- 
bidity indicates  an  impure  specimen  of  creosote.  The  average  dose 
is  4  min.  (0.25  mil).  The  one  oflEicial  preparation.  Aqua  Creosoti, 
is  not  much  used  in  dentistry.  As  stated  above,  the  chief  con- 
stituents of  creosote  are  guaiacol  and  creosol;  the  former  is  official. 

GUAIACOL— U.S.P. 

Guaiacol  is  a  phenol  derivative  obtained  by  fractional  distilla- 
tion from  creosote.  It  is  a  colorless,  oily  liquid,  having  a  rather 
unpleasant  aromatic  odor  and  taste.  It  is  sparingly  soluble  in 
water,  freely  so  in  alcohol  and  ether.  The  average  dose  is  8  min. 
(0.5  mil). 

Physiologic  Action. — Like  all  members  of  the  phenol  groups, 
creosote  is  an  antiseptic,  disinfectant,  caustic  and  local  analgesic. 
Its  action  closely  resembles  that  of  phenol,  but  it  is  less  irritant  and 
toxic. 

Therapeutics. — Creosote  is  employed  in  dental  practice  chiefly  as 
a  disinfectant  and  local  analgesic.  It  is  probably  used  more  because 
of  its  analgesic  property  than  any  other.  Three  or  four  minim's 
(0.18-0.24  mil)  placed  on  a  blank  tablet,  a  piece  of  loaf  sugar, 
or  candy  form  a  valuable  remedy  for  preventing  nausea  in  taking 
impressions.  This  should  be  held  in  the  mouth  until  the  vehicle  is 
dissolved.     Creosote  mixed  with  an  equal  volume  of  Hquor  for- 


FORMALDEHYDUM  67 

maldehyd,  to  which  a  small  quantity  of  alcohol  (20  min.  to  the  ounce 
— 1.3-30.0  mils)  is  added,  makes  an  excellent  remedy  for  the  treat- 
ment of  gangrenous  pulp  conditions.  Equal  volumes  of  creosote 
and  tincture  of  iodin  have  long  been  employed  as  a  local  analgesic 
and  stimulant  in  apical  pericementitis.  Care  must  be  taken  to  pre- 
vent the  remedy  from  staining  the  dentin  of  the  crown  of  the  tooth, 
causing  discoloration.  Creosote  is  largely  used  as  a  toothache 
remedy  by  the  laity.  Guaiacol  is  not  much  used  in  dentistry,  but 
is  used  in  medicine  in  pulmonary  tuberculosis  as  a  substitute  for 
creosote. 

FORMALDEHYDUM  (Nonofficial) 

(Formaldehyd ;  Formic  Aldehyd;,  CH2O.) 

Formaldehyd  is  a  colorless  gas,  having  a  very  pungent  odor, 
obtained  by  the  partial  oxidation  of  methyl  alcohol  (wood-alcohol). 
The  Pharmacopeia  recognizes  a  37  per  cent,  aqueous  solution  of  the 
gas  under  the  name  Liquor  Formaldehydi — Solution  of  Formaldehyd. 
Various  solutions  of  the  gas  are  on  the  market,  commercially  called 
formalin,  formol,  etc.  The  gas  in  solution  readily  undergoes  poly- 
merization, whereby  a  solid  form  is  obtained,  now  also  recognized 
by  the  U.S. P.  as  Paraformaldehyd  and  called  synonymously 
trioxymethylen  or  parajorm  (CH2O3).  This  is  a  white  crystalline 
powder,  which  yields  formaldehyd  on  heating,  or  at  body  tempera- 
ture.    The  average  dose  is  8  gr.  (0.5  Gm.). 

Physiologic  Action. — Formaldehyd  is  one  of  the  best  disin- 
fectants. Stevens  states  that  a  i  per  cent,  solution  of  liquor  for- 
maldehyd kills  pure  cultures  of  pathogenic  bacteria  in  an  hour.  It 
is  a  powerful  deodorizer,  readily  uniting  with  hydrogen  sulphid, 
mercaptan,  ptomains,  ammonia,  and  fetid  ammonia  bases  to  form 
inodorous  compounds. 

The  gas  is  intensely  irritating;  when  inhaled  it  causes  severe 
hyperemia  and  even  inflammation  of  the  mucous  membrane  of  the 
entire  respiratory  tract.  Concentrated  solutions  will  produce  a 
slough  almost  as  readily  as  arsenic  trioxid. 

The  antidote  for  formaldehyd  poisoning  is  ammonia,  with  which 
it  forms  the  harmless  hexamethylenamin  (urotropin) . 

Therapeutics. — Because  of  the  power  formaldehyd  has  of  uniting 
with  the  intermediate  and  end-products  of  pulp  decomposition,  form- 
ing with  them  nonpoisonous  substances  and  converting  the  gases  into 
liquids  and  solids,  it  is  a  most  essential  constituent  of  gangrenous 
pulp  remedies.  Its  irritating  action  can  be  controlled  by  mixing  the 
official  liquor  formaldehyd  with  cresol,  phenol,  or  creosote.     The 


68  ANTISEPTICS,    DISINFECTANTS,    AND   DEODORANTS 

author's  formocresol  remedy  is  equal  volumes  of  cresol  and  liquor 
formaldehyd.  When  used,  this  remedy  should  always  be  hermeti- 
cally sealed  within  the  tooth  with  a  nonyielding  sealing  material, 
such  as  the  dental  cements. 

A  lo  per  cent,  solution  of  liquor  formaldehyd,  to  which  2  per  cent, 
of  borax  or  sodium  carbonate  is  added,  makes  an  excellent  sterilizing 
fluid  for  small  instruments.  The  alkaHne  salt  (borax  or  sodium 
carbonate)  prevents  the  formaldehyd  from  attacking  the  metal.  In 
weak  solutions  (i :  1,000  to  i :  500)  it  may  be  added  to  mouth- washes 
and  sprays.  Apparatus  are  on  the  market  for  using  paraform  for 
sterilizing  instruments.  Probably  the  only  objection  to  this  method 
is  the  liability  of  the  gas  escaping  in  the  office.  Some  individuals  are 
peculiarly  susceptible  to  formaldehyd,  having  an  idiosyncrasy  for  the 
drug.  The  author  has  known  of  a  few  such  cases  among  dentists, 
where  even  a  slight  exposure  to  the  gas  would  cause  red  blotches  on 
the  face  and  hands,  resulting  in  desquamation  (^scaling).  The  con- 
dition has  been  erroneously  diagnosed  as  psoriasis,  a  chronic  inflam- 
matory disease  of  the  skin  characterized  by  the  development  of  red- 
dish patches  covered  with  whitish  scales.  Individuals  thus  affected 
should  avoid  exposure  in  any  manner  to  formaldehyd.  Fortunately 
these  cases  are  rare,  for  the  drug  is  a  valuable  one  in  dental  practice, 
if  properly  used. 

In  medicine  formaldehyd  is  extensively  employed  as  a  surface 
disinfectant  for  rooms  containing  the  germs  of  contagious  diseases. 
Both  the  aqueous  solutions  and  the  solid  paraform  are  used  for  this 
purpose. 

iQCompatibilities. — Formaldehyd  is  incompatible  with  ammonia, 
alkalies,  tannic  acid,  and  mineral  salts. 


HEXAMETHYLENAMINA— U.S.P. 

(Hexamethylenamin;  Uro tropin.) 

Hexamethylenamin,  or  urotropin,  is  the  product  formed  by  the 
action  of  formaldehyd  on  ammonia.  It  is  not  used  in  dental  practice, 
but  mentioned  here  because  of  its  formation  within  the  tubular  struc- 
ture of  the  dentin  when  formaldehyd  gas  is  sealed  within  a  gangren- 
ous root  canal.  The  average  dose  is  4  gr.  (0.25  Gm.).  The  drug  is 
especially  indicated  in  suppurative  diseases  of  the  genito-urinary 
tract;  and  is  also  frequently  given  in  severe  sore  throat,  especially  in 
cases  of  infection  by  the  streptococcus  germ. 


LIQUOR  HYDROGENII  DIOXIDI  69 

LIQUOR  HYDROGENH  DIOXIDI— U.S.P. 

(Solution  of  Hydrogen  Dioxid;  H2O2.) 

Hydrogen  dioxid  is  a  very  unstable  compound,  prepared  by  the 
action  of  mineral  acids  (usually  sulphuric  acid)  on  barium  dioxid. 
The  offi  cial  aqueous  solution  should  contain,  when  freshly  prepared, 
about  3  per  cent,  by  weight  of  absolute  hydrogen  dioxid,  which  cor- 
responds to  about  10  volumes  of  available  oxygen.  In  previous 
pharmacopeias  the  solution  was  classified  as  a  "water."  It  is  now 
properly  classified  as  a  "liquor."  The  solution  is  a  colorless  liquid, 
without  odor,  sHghtly  acidulous  to  the  taste,  and  producing  a  pecu- 
liar sensation  and  a  soapy  froth  in  the  mouth.  It  is  Uable  to  deterio- 
rate with  age  or  by  exposure  to  heat  or  protracted  agitation.  The 
dose  is  I  fi.  dr.  (4.0  mils),  well  diluted  with  water. 

There  is  an  unofl&cial  ethereal  solution  of  hydrogen  dioxid  on  the 
market  which  contains  25  per  cent,  of  the  drug. 

Physiologic  Action. — When  hydrogen  dioxid  is  applied  to  mucous 
membranes  it  decomposes  into  water  and  oxygen,  the  latter  being 
given  off  in  large  quantities.  The  oxygen  thus  Hberated  is  in  the 
nascent  state  and  readily  oxidizes  surrounding  substances.  Applied 
to  suppurating  wounds  or  abraded  surfaces,  effervescence  follows 
from  the  free  oxygen.  This  effervescence  is  not  necessarily  an  indi- 
cation of  the  presence  of  infection  or  pus,  as  hydrogen  dioxid  will  pro- 
duce effervescence  when  in  contact  with  blood.  Hydrogen  dioxid, 
because  of  the  Hberation  of  nascent  oxygen,  destroys  healthy  granu- 
lations in  healing  wounds  and  should,  therefore,  be  employed  with 
caution,  if  used  at  all.  It  may  cause  sudden  death  when  injected 
hypodermically  or  intravenously  by  the  formation  of  gaseous  emboli 
in  a  blood-vessel. 

Therapeutics. — As  a  cleansing  agent  and  disinfectant,  hydrogen 
dioxid  has  been  extensively  applied  to  diseased  surfaces,  such  as 
canker  sores  and  other  ulcers,  pyorrheal  pockets,  sinuses,  etc.  It  is 
used  extensively  by  the  laity  for  cuts  and  bruises.  It  has  little  value 
here  as  a  therapeutic  agent,  except  that  the  effervescence  caused  by 
its  action  on  the  blood  may  mechanically  remove  dirt  or  other  foreign 
bodies.  In  diluted  solution  it  has  been  much  used  as  an  antiseptic 
remedy  in  many  diseases  of  the  mouth,  throat,  and  nose.  The  drug 
may  be  used  as  a  gargle  or  spray,  or  applied  with  a  syringe  or  a  swab. 
The  value  of  hydrogen  dioxid  as  a  therapeutic  agent  depends  upon 
the  readiness  with  which  it  liberates  oxygen  when  it  is  brought  in  con- 
tact with  abraded  tissues  and  with  the  fluids  of  the  body.  It  should, 
therefore,  be  used  with  great  caution  in  all  practically  closed  sinuses 


70  ANTISEPTICS,    DISINFECTANTS,    AND   DEODOEANTS 

and  on  granulating  surfaces.  While  the  drug  has  its  use  in  dental 
practice,  its  real  value  has  been  overestimated,  and  much  harm  has 
resulted  from  its  injudicious  employment.  It  is  used  for  moistening 
pumice  in  prophylactic  work;  the  only  objection  to  its  employment 
here  is  that  the  agent  causes  effervescence  and  hides  the  field  of  opera- 
tion. As  a  cleansing  and  whitening  agent  for  the  teeth,  it  is  also 
used  by  the  laity,  but  its  continued  use  as  a  mouth-wash  is  likely  to 
affect  deleteriously  the  tooth-structure,  on  account  of  the  uncombined 
sulphuric  acid  it  contains.  This  latter  agent  seems  necessary  to 
preserve  the  solution,  and  is  added  by  manufacturers.  As  a  bleach- 
ing agent  it  is  of  great  value.  The  preparation  mostly  used  for 
bleaching  tooth-structure  is  the  25  per  cent,  ethereal  solution. 

POTASSn  PERMANGANAS— U.S.P. 

(Potassium  Permanganate;  KMn04.) 

Potassium  pennanganate  occurs  in  the  form  of  slender,  dark- 
purple  prisms,  odorless,  and  of  a  sweetish,  astringent  taste.  It  is 
soluble  in  13.5  parts  of  water  at  25°C.,  and  is  decomposed  by  alcohol 
and  hydrogen  dioxid.  It  should  be  kept  in  glass-stoppered  bottles, 
protected  from  light,  and  care  should  be  taken  not  to  bring  it  in 
contact  with  organic  or  readily  oxidizable  substances.  The  average 
dose  is  I  gr.  (0.06  Gm.). 

Physiologic  Action. — In  the  presence  of  organic  matter  potassium 
permanganate  quickly  yields  its  oxygen;  hence  it  is  a  good  disinfect- 
ant and  deodorant.  Its  usefulness,  however,  is  limited,  for  when  its 
oxygen  is  given  up  it  is  rendered  inert. 

Therapeutics. — Its  readiness  to  part  with  oxygen  renders  it  of 
great  value  as  a  deodorant,  and  in  dilute  solutions,  1-5  gr.  (0.06-0.32 
Gm.)  to  I  ounce  (30.0  mils)  of  water,  it  is  a  useful  remedy  in  thrush^ 
foul  ulcers,  putrid  sore  throat,  syphilitic  chancre,  and  cancer  of  the 
tongue. 

It  is  employed  in  surgical  practice  for  disinfecting  the  hands,  and 
should  be  followed  with  a  saturated  solution  of  oxalic  acid  to  remove 
the  stain.  Its  disadvantage  for  use  in  the  mouth  is  its  tendency  to 
discolor  the  enamel  of  the  teeth.  This  is  only  a  surface  and,  therefore, 
temporary  discoloration. 

Incompatibilities. — Potassium  permanganate  is  incompatible 
with  organic  substances,  alcohol,  and  hydrogen  dioxid. 

CHINOSOL  (Nonofficial) 

Chinosol  occurs  as  a  yellowish,  crystalline  powder,  having  a 
saffron-like  odor  and  a  burning  taste;  soluble  in  water,  but  insoluble 


HYDRARGYRI    CHLORIDUM    CORROSIVUM  7 1 

in  alcohol  and  ether.     The  aqueous  solution  has  an  acid  reaction. 
The  average  dose  is  5  gr.  (0.3  Gm.). 

Physiologic  Action  and  Therapeutics. — Chinosol  is  a  powerful 
antiseptic.  Cook  and  Mawhinney  have  spoken  highly  of  the  drug 
as  a  pus-destroyer,  recommending  its  free  use  in  from  i  to  10  per 
cent,  solutions  in  foul,  chronic  abscesses  and  all  other  violent  suppura- 
tions. Experimental  evidence  thus  far  has  proven  chinosol  to  be  non- 
toxic. As  a  disinfectant  it  is  weaker  than  phenol,  and  much  weaker 
than  mercuric  chlorid ;  though  as  an  antiseptic  it  is  considered  stronger 
than  and  preferable  to  either  of  these  drugs.  It  has  been  found 
to  exert  a  restraining  (antiseptic)  influence  on  germs  in  solutions  con- 
taining I  part  to  10,000.  The  drug  does  not  coagulate  albumin  nor 
injure  the  mucous  membranes  or  tissues.  Therefore,  its  solution  in 
various  strengths  is  used  to  advantage  in  treating  many  conditions 
in  both  medicine  and  dentistry.  As  an  antiseptic  wash  the  average 
strength  of  solution  is  i:  1,000.  In  gargles  the  strength  may  be  in- 
creased to  1 :  250.  The  drug  is  claimed  to  possess  marked  analgesic 
power  and  to  be  an  efficient  deodorant. 


HYDRARGYRI  CHLORIDUM  CORROSIVUM— U.S.P. 

While  mercuric  chK)rid  will  be  discussed  with  the  class  of  altera- 
tives under  Mercury  and  its  Compounds  (see  p.  198),  the  class  of 
disinfectants  would  indeed  be  incomplete  without  the  mention  of  this 
important  and  valuable  drug. 

Mercuric  chlorid  is  the  most  popular  of  aU  the  disinfectants  for 
surgical  work.  The  drug  is  cheap,  soluble,  and  attacks  bacteria  and 
their  by-products  with  energy.  However,  there  are  three  principal 
objections  to  its  employment:  It  is  extremely  poisonous;  it  attacks 
metallic  instruments  detrimentally;  and  it  readily  acts  upon  albumin- 
ous matter,  rendering  the  drug  inert.  Stevens  claims  this  last  ob- 
jection may  be  eliminated  by  adding  to  its  solution  a  weak  acid 
(tartaric  or  citric  acid) , 

Heat  is  a  valuable  disinfectant,  and  without  doubt  is  the  most 
reliable  for  sterilizing  instruments.  All  known  pathogenic  bacteria 
and  their  spores  are  destroyed  by  heat.  The  best  method  of  steril- 
izing operative  and  surgical  instruments  is  to  immerse  them  in  boiling 
water  for  from  2  to  15  minutes,  according  to  the  demands  of  the  case. 
Many  practical  ''sterilizers"  are  on  the  market  for  this  purpose  (see 
p.  278). 


72  ASTRINGENTS,    STYPTICS,    AND   HEMOSTATICS 

ASTRINGENTS,  STYPTICS,  AND  HEMOSTATICS 

Astringents  are  agents  which  produce  contraction  and  condensa- 
tion of  tissue.  Styptics  and  hemostatics  apply  to  agents  that  arrest 
hemorrhage.  When  the  agent  is  applied  locally  it  is  called  a  styptic; 
when  administered  internally  it  is  called  a  hemostatic.  Many  of  the 
styptic  and  hemostatic  agents  control  hemorrhage  by  virtue  of  their 
astringent  property,  for  which  reason  these  classes  of  remedies  are 
discussed  here  conjointly.  Astringent  agents  exert  their  influence 
most  markedly  when  applied  upon  raw  surfaces  and  mucous  mem- 
branes. Many  of  them  also  have  the  property  of  diminishing  or  ar- 
resting glandular  secretion.  This  result  is  produced  more  by  the 
direct  action  of  the  agent  upon  the  secreting  cell  than  it  is  by  the  con- 
striction of  the  blood-vessels  of  the  part.  Cook,  in  his  experiments 
upon  dogs,  has  shown  that  mouth-washes  which  contain  astringent 
agents,  notably  zinc  chlorid,  arrest  the  secretion  of  ptyaHn  for  a  con- 
siderable number  of  hours  after  the  solution  is  employed. 

Most  of  the  astringents  are  also  irritants ;  especially  is  this  true  of 
some  of  the  metallic  salts,  the  action  of  which  is  more  irritant  and 
caustic  than  astringent.  This  is  largely  due  to  the  liberation  of 
an  acid  by  the  union  of  the  metal  with  the  albumin  of  the  cells. 

Astringents  may  be  conveniently  divided  into  two  classes,  vege- 
table and  mineral.  The  efficacy  of  those  of  vegetable  origin  depends 
upon  the  tannic  acid  which  they  contain.  It  should  be  remembered 
that  among  the  mineral  astringents,  bismuth  subnitrate,  zinc  oxid, 
and  lead  acetate  have  more  of  a  sedative  than  an  irritant  action. 
The  vegetable  astringents  of  importance  are: 

Tannic  acid.  Ergot. 

Gallic  Acid.  Krameria. 

Hematoxylon.  HamameKs. 
Hydrastis. 

The  important  mineral  astringents  are: 

Alum.  Zinc  Oxid. 

Lead  Acetate.  Zinc  lodid. 

Copper  Sulphate.  Zinc  Chlorid. 

Zinc  Sulphate.  Calcium  Chlorid. 

Zinc  Phenolsulphonate.  Bismuth  Subnitrate. 

Silver  Compounds. 

ACmUM  TANNICUM— U.S.P. 

(Tannic  Acid;  Tannin;  HC14H9O9.) 

Tannic  acid  is  the  active  constituent  of  all  vegetable  astringents. 
Its  chief  source  is  from  nutgall.     It  occurs  in  the  form  of  a  light- 


ACIDUM   TANNICUM  73 

yellowish,  amorphous  powder,  odorless,  and  of  a  strongly  astringent 
"taste.  Soluble  in  about  0.34  part  of  water  and  in  0.23  part  of  alcohol; 
also  soluble  in  about  i  part  of  glycerin  with  the  aid  of  moderate  heat. 
The  average  dose  is  8  gr.  (0.5  Gm.). 

All  of  the  official  preparations  are  valuable  astringent  remedies. 
They  are: 

Glyceritum  Acidi  Tannici,  Glycerite  of  Tannic  Acid  (20  per 

cent.). 

Unguentum  Acidi  Tannici,  Ointment  of  Tannic  Acid  (20  per 

cent.). 

Trochisci  Acidi  Tannici,  Troches  of  Tannic  Acid  (i  gr.-o.o6 

Gm.  in  each). 

CoUodium    Stypticum,    Styptic    Collodion   (20    per    cent.), 

u.s.p.  vni. 

Physiologic  Action. — Tannic  acid,  especially  when  applied  to  raw 
surfaces,  coagulates  the  albumin  of  the  superficial  celis,  causing  con- 
densation of  the  tissue,  which  is  evidenced  by  the  sensation  of  puck- 
ering. On  mucous  membranes  it  acts  in  a  similar  manner,  combin- 
ing with  the  proteids  of  the  glandular  cells,  thus  drying  up  the  secre- 
tion. It  also  paralyzes  the  sensory  nerve-endings  and  blunts  the 
sense  of  taste.  It  may  be  considered  a  styptic,  as  it  coagulates  the 
albumin  of  the  blood  and  checks  hemorrhage.  When  administered 
internally,  tannic  acid  is  changed  in  the  intestine  into  gallic  acid,  and 
in  this  form  a  certain  amount  is  absorbed  and  eliminated  in  the  urine ; 
it  also  acts  as  a  hemostatic. 

Therapeutics. — Tannic  acid  is  a  valuable  astringent  drug.  It 
may  be  appUed  locally  in  the  form  of  the  glycerite  in  cases  of  spongy 
gums,  or  the  glycerite  may  be  added  to  mouth-washes  to  the  extent 
of  from  2  to  5  per  cent.,  thus  giving  to  the  solution  an  astringent 
property.  For  years  the  glycerite  was  appHed  to  the  pulp  tissue 
after  devitalization  for  the  purpose  of  toughening  the  tissue  and  aid- 
ing in  its  subsequent  removal  from  the  canals  of  teeth,  but  its  liability 
to  discolor  the  tooth-structure  when  so  used  constitutes  a  serious 
objection  to  its  employment  (see  p.  329). 

A  solution  of  from  3^  to  i  per  cent,  is  a  useful  remedy  to  be  used 
as  a  spray  or  gargle  in  cases  of  stomatitis,  laryngitis,  and  pharyngitis. 
Many  dentists  are  troubled  with  hy paridrosis  of  the  hands.  Lotions 
containing  tannic  acid  are  often  beneficial  in  this  condition.  Dust- 
ing-powders, as  well  as  lotions,  are  also  used  in  hyperidrosis  of  the 
feet. 

Styptic  collodion  serves  as  a  protection  to  lacerated  or  incised 


74  ASTRINGENTS,    STYPTICS,    AND   HEMOSTATICS 

wounds.     Troches  of  tannic  acid  may  be  dissolved  in  the  mouth  with 
benefit  in  cases  of  sore  throat. 

Incompatibility. — Tannic  acid  is  incompatible  with  alkaloids, 
gelatin,  lime-water,  the  salts  of  iron,  silver,  lead,  and  copper.  When 
potassium  chlorate  is  triturated  with  tannic  acid  or  organic  drugs 
containing  the  latter,  the  mixture  is  liable  to  explode. 

ACmUM  GALLICUM 
(Gallic  Acid;  HC7H5O5  +  H2O.) 

Gallic  acid  is  prepared  generally  from  tannic  acid.  It  occurs 
as  white  or  pale  fawn-colored,  silky  needles,  odorless,  having  an  as- 
tringent or  slightly  acidulous  taste.  It  is  soluble  in  87  parts  of 
water,  in  4,6  parts  of  alcohol,  and  in  10  parts  of  glycerin  at  25°C. 
The  average  dose  is  15  gr.  (i.o  Gm.),  given  in  powders  or  capsules. 

Physiologic  Action. — Gallic  acid  resembles  tannic  acid  when  ad- 
ministered internally;  but,  applied  locally,  it  is  a  very  feeble  astrin- 
gent, as  it  does  not  coagulate  albumin  and  hence  does  not  influence 
the  tissue  Hke  tannic  acid. 

Therapeutics. — ^About  the  only  indication  for  gallic  acid  in  dental 
practice  is  in  cases  of  hemorrhage  following  extraction.  Here  it  would 
be  employed  purely  as  a  hemostatic,  and  its  action  as  such  is  ques- 
tionable, except  in  intestinal  hemorrhage. 

KRAMERIA  (Nonofficial) 
(Krameria ;  Rhatany.) 

Krameria  is  the  dried  root  of  Krameria  triandra,  a  low  shrub  grow- 
ing in  sandy  locaHties  in  the  mountains  of  Bolivia  and  Peru. 
Tannic  acid  is  the  chief  constituent.  The  following  preparations, 
which  with  the  drug  itself  were  official  in  the  U.S. P.  VIII,  are  of 
value  in  dentistry: 

Extractum  Krameriae.     Average  dose,  5  gr.  (0.3  Gm.). 
Fluidextractum  Krameriae.     Average  dose,  10  min.  (0.6  mils). 
Syrupus  Krameriae.     Average  dose,  i  fl.  dr.  (4.0  mils). 
Tinctura  Krameriae.     Average  dose,  }-2  fl.  dr.  (2.0  mUs). 
Trochisci  Krameriae.     Average  dose,  2  troches  (each  contains 
I  gr.-o.o6  Gm.  of  the  extract). 

Phyiologic  Action. — The  action  of  krameria  is  identical  with  that 
of  its  chief  constituent,  tannic  acid. 

Therapeutics. — The  astringency  of  the  drug  is  due  entirely  to  the 
tannic  acid  which  it  contains  in  large  amount.  It  has  no  special  ad- 
vantage over  tannic  acid.     The  various  preparations  of  krameria, 


ELAMAMELIS — ^HiEMATOXYLO  N  75 

especially  the  tincture,  may  be  added  to  mouth-washes  and  gargles 
to  be  used  in  cases  of  rubber  sore  mouth,  spongy  gums,  ptyalism,  and 
pharyngitis.     The  troches  are  also  useful  in  sore  throat. 

HAMAMELIS  (Nonofficial) 
(Witch-hazel.) 

Hamamelis  was  formerly  official  as  the  bark  and  dried  leaves  of 
Hamamelis  Virginiana,  a  shrub  growing  in  the  damp  woods  of  North 
America.  It  contains  a  volatile  oil,  a  small  amount  of  tannic  acid, 
and  a  bitter  principle.     The  official  preparations  are: 

AquaHamamelidis,  U.S.P.;  distilled  extract  of  Witch-hazel. 
Average  dose,  2  fl.  dr.  (8.0  mils). 

Physiologic  Action. — The  action  of  hamamelis  is  that  of  an  astrin- 
gent, due  largely  to  the  tannic  acid  it  contains.  Besides  its  astringent 
property,  the  drug  is  credited  with  having  a  marked  sedative  effect 
when  topically  applied. 

Therapeutics.- — Preparations  of  hamameUs  are  useful  household 
remedies.  As  a  topical  application  after  shaving,  and  for  sprains  and 
bruises  hamamelis  water  has  long  enjoyed  a  popular  reputation. 
Diluted  with  water,  alcohol,  or  glycerin  (i  part  to  3),  the  distilled  ex- 
tract may  be  used  as  a  spray  in  inflamed  and  spongy  gums,  in  pharyn- 
gitis, and  applied  to  the  nasal  mucous  membrane  after  the  removal 
of  polypi. 

Hamamelis  water  has  been  recommended,  diluted  one-haH  with 
distilled  water,  as  a  vehicle  for  local  anesthetic  solutions.  It  should 
not  be  so  employed,  as  the  tannic  acid  will  act  upon  the  alkaloidal 
salt  (usually  cocain  hydrochlorid)  and  precipitate  the  alkaloid. 

HLffiMATOXYLON  (Nonofficial) 

(Logwood.) 

Hematoxylon  is  the  heart-wood  of  Hcematoxylon  campechianum, 
a  rather  small  tree  growing  along  the  shores  of  the  Gulf  of  Campeachy 
and  in  certain  parts  of  South  America.  Besides  tannic  acid  it  con- 
tains a  crystalline  coloring  principle,  hematoxylin.  The  extract  as 
well  as  the  drug  itself  was  official  in  the  U.S. P.  VIII.  The  drug  has 
no  dental  use  except  as  a  staining  agent  for  tissues  in  microscopic 
study,  for  which  purpose  it  is  extensively  employed,  and  may  be 
found  among  the  "reagents"  of  Part  II,  U.S. P.  IX. 


76  ASTRINGENTS,    STYPTICS,    AND   HEMOSTATICS 

ERGOTA— U.S.P. 

(Ergot;  Ergot  of  Rye.) 

Ergot  is  the  sclerotium  of  Clavicefs  purpurea,  a  parasitic  fungus, 
which  replaces  the  grain  of  rye,  Secale  cereale.  Ergot  is  obtained 
chiefly  from  the  rye  growing  in  Russia,  Spain,  and  Germany.  The 
following  preparations  are  official : 

Fluidextractum  Ergotse,  U.S. P.     Average  dose,  30  min.  (2.0  mils). 
Extractum  Ergotse,  U.S. P.    Average  dose,  4  gr.  (0.25  Gm.). 

Physiologic  Action. — Ergot  has  no  local  action.  The  drug  must 
be  taken  internally  to  produce  its  effects.  When  it  enters  the  circu- 
lation it  acts  directly  upon  the  muscular  coats  of  the  vessels,  causing 
constriction  of  the  arterioles,  with  an  increase  in  arterial  pressure. 
The  involuntary  muscles  throughout  the  body  appear  to  be  influenced 
by  ergot;  the  voluntary  muscles  are  unaffected. 

Therapeutics. — Ergot  is  used  in  dentistry  for  its  hemostatic  prop- 
erty. In  cases  of  known  hemorrhagic  diathesis  {hemophilia) ,  it  is  well 
to  administer  the  drug  a  few  hours  previous  to  the  extraction  of  teeth 
or  other  operations  involving  hemorrhage.  The  fluid  extract  is  the 
most  reliable  preparation  and  may  be  given  in  doses  of  3^^-!  fl.  dr. 
(2.0-4.0  mils). 

Ergot  should  not  be  given  when  the  hemorrhage  proceeds  from  a 
large  vessel,  because  here  the  muscular  contraction  could  not  close 
the  vessel,  and  the  increased  arterial  pressure,  occasioned  by  the 
drug,  would  naturally  increase  the  flow  of  blood. 

The  drug  should  not  be  given  to  pregnant  women,  because  of  the 
contraction  it  produces  on  the  unstriped  muscle  of  the  uterus.  Ergot 
is  the  one  drug  relied  upon  to  prevent  postpartum  hemorrhage  during 
and  following  labor  in  confinement  cases. 

HYDRASTIS— U.S.P. 

(Golden  Seal.) 

Hydrastis  is  the  dried  rhizome  and  roots  of  Hydrastis  canadensis, 
a  perennial  herb  growing  in  the  woods  of  North  America.  One  of  the 
chief  constituents  is  hydrastin,  which  is  official  under  the  title 
Hydrastina.  Hydrastin  hydrochlorid,  Hydrastinse  Hydrochloridum, 
is  also  official;  as  is  also  the  hydrochlorid  of  an  alkaloid  obtained  by 
the  oxidation  of  hydrastin,  called  Hydra stinin  Hydrochlorid,  Hy- 
dras tininae  Hydrochloridum.  Other  constituents  are  herherin  and 
canadin. 


SUPRAEENALUM  SIC  CUM  77 

The  official  preparations  of  Hydrastis  are : 

Fluidextractum  Hydrastis,  U.S.P.     Average  dose,  30  min. 
(2.0  mils). 

Tinctura  Hydrastis,  U.S.P.     Average  dose,  i  dr.  (4.0  mils). 
Glyceritum  Hydrastis,  U.S.P.     Externally. 

Physiologic  Action  and  Therapeutics. — The  action  of  Hydrastis 
is  due  almost  entirely  to  the  presence  of  the  alkaloid,  hydrastin,  which 
it  contains.  Applied  locally,  it  appears  to  have  a  stimulating  influ- 
ence upon  the  oral  mucous  membrane.  The  glycerite  may  be  added 
to  mouth-washes  (5  per  cent.)  and  used  in  sluggish  conditions  of 
the  mucous  membranes,  as  in  chronic  catarrh,  etc.  The  drug  also 
has  astringent  and  antiseptic  properties.  The  fluid  extract  appHed 
to  indolent  ulcers  stimulates  the  condition  to  a  healthy  activity.  In- 
ternally administered  it  acts  as  a  stomachic  and  is  a  constituent  of 
many  bitter  tonics. 

Incompatibles. — These  are  the  same  as  those  of  other  alkaloids. 

SUPRARENALUM  SICCUM— U.S.P. 
(Desiccated  Suprarenal  Glands;  Suprarenal  Extract.) 

This  product  is  neither  a  vegetable  nor  mineral  astringent,  but  is 
considered  here  because  it  belongs  to  this  group.  It  is  the  suprarenal 
gland  of  the  animals  which  are  used  for  food  by  man  (sheep,  ox, 
etc.),  freed  from  fat,  cleaned,  dried,  and  powdered;  and  containing 
not  less  than  0.4  per  cent,  nor  more  than  0.6  per  cent,  of  epinephrin, 
the  active  principle  of  the  suprarenal  gland.  It  occurs  as  a  light, 
yellowish-brown  powder,  having  a  slight,  characteristic  odor; 
partially  soluble  in  water.     The  average  dose  is  4  gr.  (0.25  Gm.). 

The  active  principle  has  been  separated  by  different  men  and 
variously  named  epinephrin  (Abel),  suprarenin  (Von  Furth),  adrena- 
lin (Takamine  and  Aldrich).  According  to  the  best  authoritiesfihe 
last-named,  adrenalin,  represents  more  fully  the  active  properties  of 
the  gland.  It  occurs  as  a  white,  crystalline  substance.  It  dissolves 
with  difficulty  in  cold  water;  but  dissolves  readily  in  acids,  forming 
salts.  A  solution  of  adrenalin  chlorid  is  on  the  market,  as  are  other 
liquids  and  solids  for  styptic  and  hemostatic  purposes.  Epinephrin 
is  produced  synthetically  and  is  on  the  market  in  various  forms 
under  the  name  "L. -Suprarenin  Synthetic. " 

Physiologic  Action  and  Therapeutics.- — Suprarenal  gland,  or 
solutions  of  its  active  principle,  act  locally  on  a  variety  of  structures, 
probably  by  stimulating  the  sympathetic  nerve  terminals.  Its  most 
important  action  is  the  constriction  of  blood-vessels,  with  the  usual 


78  ASTRINGENTS,    STYPTICS,   AND   HEMOSTATICS 

high  rise  of  blood  pressure.  The  drug  is  used  in  dentistry  largely  for 
its  hemostatic  properties.  It  should  be  remembered  that  the  solution 
of  epinephrin  (adrenalin,  suprarenin)  will  better  prevent  hemorrhage 
if  used  before  operating  than  it  will  check  hemorrhage  after  it 
has  begun.  Braun,  Fischer  and  others  recommend  its  use  for  the 
vasoconstrictor  action  to  intensify  and  prolong  the  anesthetic  effect 
of  local  anesthetics  by  retarding  the  circulation  in  the  affected  part 
and  thus  hindering  the  dilution  of  the  anesthetic  agent  by  too  rapid 
absorption  into  the  general  blood  stream.  Solutions  of  adrenalin 
chlorid  have  been  recommended  as  the  vehicle  for  dissolving  cocain 
hydrochlorid  in  the  removal  of  the  dental  pulp  by  pressure  anesthe- 
sia. Its  use  here,  however,  is  unwarranted  and  objectionable  (see 
Practical  Therapeutics,  p.  323). 

The  dilute  aqueous  solutions  are  rather  unstable,  the  deterioration 
being  accompanied  by  a  reddish  or  brownish  discoloration.  The 
drug  can  be  obtained  alone  or  combined  with  other  drugs,  in  tablet 
form.     The  powder  is  stable. 

THYROrOEUM  SICCUM— U.S.P. 

(Desiccated  Thyroid  Glands;  Thyroid  Extract.) 
This  product  is  the  thyroid  gland  of  animals  which  are  used  for 
food  by  man,  freed  from  fat,  cleaned,  dried,  and  powdered.  It  must 
contain  not  less  than  0.17  per  cent,  nor  more  than  0.23  per  cent,  of 
iodin  in  thyroid  combination.  One  part  represents  approximately 
5  parts  of  the  fresh  gland.  It  is  a  yellowish,  amorphous  powder, 
partially  soluble  in  water.  Average  dose,  i3^  gr.  (o.i  Gm.).  The 
product  is  not  much  used  in  dentistry,  its  general  properties  being 
alterative,  hemostatic,  and  antifat. 

ALUMEN— U.S.P. 

(Alum.) 

The  United  States  Pharmacopeia  now  recognizes  two  kinds  of 
alum — ammonium  alum  and  potassium  alum.  The  ammonium  or 
potassium  is  combined  chemically  with  aluminum  in  the  form  of  a 
sulphate,  and  is  what  is  known  in  chemistry  as  a  double  sulphate. 
Both  occur  in  large,  colorless,  octahedral  crystals,  odorless,  but  hav- 
ing a  sweetish  and  strongly  astringent  taste.  Soluble  in  water 
and  in  warm  glycerin,  insoluble  in  alcohol.  The  ammonium  alum  is 
somewhat  less  soluble  in  water  than  is  the  potassium  alum.  The 
average  dose  is  8  gr.  (0.5  Gm.) .  As  an  emetic  it  may  be  given  in  much 
larger  doses — 1-2  dr.  (4.0-8.0  Gm.).  The  dried  or  burnt  alum  is  also 
ofl&cial  under  the  title  Alumen  Exsiccatum,  U.S.P. 


PLUMBI  ACETAS  79 

Physiologic  Action. — Alum  is  a  powerful  astringent  when  appHed 
to  the  broken  skin  or  mucous  membranes.  It  acts  by  coagulating 
the  albumin  of  the  superficial  cells,  thus  causing  condensation  of  the 
tissues.  With  the  blood  it  forms  a  firm  coagulum,  and  tends  to  arrest 
hemorrhage.  When  applied  to  the  unbroken  skin,  it  has  a  tendency 
to  thicken  and  harden  it. 

Therapeutics. — In  edentulous  mouths  alum  may  be  used  to 
toughen  the  mucous  membrane.  A  solution  of  from  5  to  lo  gr. 
(0.3-0.6  Gm.)  to  the  ounce  (30.0  mils)  is  a  useful  remedy  in  cases  of 
rubber  sore  mouth,  subacute  and  chronic  pharyngitis  and  laryngitis, 
especially  where  there  is  a  viscid  mucous  secretion.  It  has  a  de- 
structive action  on  the  tooth-structure,  hence  its  prolonged  use  in  the 
mouth  is  contraindicated,  except  in  edentulous  mouths.  It  may  be 
used  as  a  styptic  to  arrest  hemorrhage  from  small  wounds.  A  large 
smooth  crystal  may  be  moistened  and  applied  to  the  face  after  shav- 
ing, as  the  alum  thickens  and  toughens  the  unbroken  skin  and  also 
tends  to  arrest  any  small  hemorrhages  which  may  follow  the  operation. 
Dried  alum  may  be  employed  as  a  mild  caustic  for  indolent  ulcers  and 
for  destroying  exuberant  granulations,  as  are  often  seen  covering  the 
fragment  of  a  broken  tooth-root  a  few  days  after  an  unsuccessful 
attempt  at  extraction. 

Lotions  of  alum  and  dilute  alcohol  are  sometimes  employed  in 
hyperidrosis  of  the  hands  and  feet. 

Incompatibles. — Alum  is  incompatible  with  alkalies,  alkaline 
carbonates,  lead  acetate,  mercury,  iron  salts,  and  tannic  acid. 

PLUMBI  ACETAS— U.S.P. 

(Lead   Acetate;    Sugar   of  Lead;   Pb(C2ll302)2  +  3H2O.) 

Lead  acetate  occurs  in  colorless,  shining,  transparent,  heavy 
prismatic  crystals  or  crystalline  masses,  having  a  faintly  acetous  odor 
and  a  sweetish,  astringent,  afterward  metallic  taste.  It  is  soluble 
in  1.4  parts  of  water  and  in  38  parts  of  alcohol  at  25°C.  The  average 
dose  is  I  gr.  (0.065  Gm.). 

Physiologic  Action. — MetaUic  lead  is  practically  inert,  and  the 
tissues  take  kindly  to  it.  A  clean  lead  bullet  may  become  encysted 
in  the  tissues.  Lead  acetate  has  valuable  therapeutic  properties. 
Applied  in  solution  to  denuded  or  highly  inflamed  surfaces,  its  action 
is  both  astringent  and  sedative.  In  the  mouth  it  acts  immediately, 
coagulating  the  mucus  and  producing  a  sweet,  styptic  taste.  When 
taken  internally  and  absorbed,  the  lead  enters  as  a  constituent  part 
into  the  protoplasm  of  the  cells,  and  is  exceedingly  slow  in  being 


8o  ASTRINGENTS,    STYPTICS,    AND    HEMOSTATICS 

eliminated.  Lead  poisoning  may  result  from  the  internal  adminis- 
tration, but  the  cases  fortunately  are  rare,  for  the  acetate  is  an  emetic 
and  the  emesis  produced  prevents  toxic  effects  of  the  drug. 

Therapeutics. — Lead  acetate  is  not  much  employed  in  dental 
practice.  Its  sedative  as  well  as  its  astringent  properties  make  it  a 
useful  drug  to  be  applied  to  acute  inflammatory  conditions  of  all 
mucous  membranes.  In  cases  of  inflammation  following  the  removal 
of  foreign  substances  from  the  eye,  a  solution  of  lead  acetate,  1-2  gr. 
(0.065-0.13  Gm.),  to  the  ounce  (30.0  mils)  of  distilled  water  makes  an 
excellent  collyrium.  Should  the  solution  be  turbid  or  milky,  it 
indicates  a  trace  of  lead  oxid.  The  smallest  amount  (i  min.-0.05 
mil)  of  dilute  acetic  acid  will  clear  the  solution. 


CUPRI  SULPHAS— U.S.P. 
(Copper  Sulphate;  Blue  Vitriol;  CUSO4  +  5H2O.) 

Copper  sulphate  occurs  in  large,  transparent,  deep-blue  crystals, 
odorless,  and  of  a  nauseous  metallic  taste.  It  is  soluble  in  about  2.5 
parts  of  water  at  25°C.,  and  almost  insoluble  in  alcohol.  The  average 
dose  as  an  astringent  is  }4  gr-  (0.032  Gm.) ;  as  an  emetic,  4  gr.  (0.25 
Gm.). 

Physiologic  Action. — The  mode  of  action  of  copper  sulphate  de- 
pends largely  upon  the  strength  of  the  solution  employed.  Dilute 
solutions  act  upon  mucous  membranes  and  raw  surfaces  as  an  astrin- 
gent. In  concentrated  solutions  or  appHed  in  the  crystal  or  pow- 
dered form,  it  acts  as  a  mild  caustic.  Internally  administered  in 
large  doses,  it  produces  emesis  by  its  direct  irritant  action  on  the 
stomach. 

Therapeutics. — Copper  sulphate  is  a  useful  drug  in  cases  of 
canker  sores,  ulcerative  stomatitis,  and  other  indolent  ulcers.  Light 
applications  of  the  solid  crystal  produce  a  stimulant  effect  upon  the 
sluggish  cells. 

It  is  a  prompt  and  powerful  emetic,  but  considered  too  irritant  to 
the  stomach  for  ordinary  use. 

Bevan  and  Brophy  report  good  results  with  copper  sulphate  in 
the  treatment  of  actinomycosis  occurring  in  man.  They  begin  with 
about  yi  gr.  (0.016  Gm.)  given  three  times  a  day,  gradually  increas- 
ing the  dose  to  i  gr.  (0.065  Gm.).  In  addition  to  the  internal  admin- 
istration of  the  drug,  irrigations  of  a  i  per  cent,  solution  are  also 
employed. 


CUPRI  OXIDUM — ZmCI  SULPHAS  8 1 

CUPRI  OXIDUM  (Nonofficial) 
(Black  Copper  Oxid;  CuO.) 

Copper  oxid  occurs  as  a  heavy  dark-brown  powder;  insoluble  in 
water.  This  product  has  been  modified  by  Ames,  and  is  used  as  the 
powder  for  the  copper  phosphate  cement,  a  material  extensively 
employed  in  filling  cavities  in  children's  teeth.  This  cement  is 
claimed  to  possess  marked  antiseptic  properties  as  well  as  serving  the 
function  of  a  temporary  filling  material.  It  has  one  distinct  advan- 
tage in  that  it  may  be  applied  directly  against  the  gums  or  other 
tissues,  which  take  kindly  to  it. 


ZINCI  SULPHAS— U.S.P. 

(Zinc  Sulphate;  White  Vitriol;  ZnSO*  +  7H2O.) 

Zinc  sulphate  occurs  in  colorless,  transparent  crystals,  or  granu- 
lar crystalline  powder,  odorless,  and  of  an  astringent  metallic  taste. 
It  is  efflorescent  in  dry  air.  Soluble  in  less  than  its  own  weight 
(0.53  part)  in  water,  in  about  2.5  parts  glycerin  at  25'^C.;  insoluble  in 
alcohol.  It  is  rarely  given  internally  except  as  an  emetic,  when  the 
average  dose  is  15  gr.  (i.o  Gm.). 

Physiologic  Action.- — Zinc  sulphate  acts  as  an  astringent,  styptic, 
emetic,  and  antiseptic.  In  weak  solutions  it  is  astringent  and  anti- 
septic; in  strong  solutions  it  acts  as  an  irritant  or  caustic,  tending  to 
arrest  slight  hemorrhage  when  applied  externally,  and,  when  admin- 
istered internally,  producing  emesis. 

Therapeutics.- — Weak  solutions  of  zinc  sulphate  may  be  applied 
to  raw  surfaces  and  to  mucous  membranes  whenever  a  sHght  astrin- 
gent effect  is  desired.  A  solution  of  from  3^-2  gr.  (0.06-0.1  Gm.) 
to  the  ounce  (30.0  mils)  is  a  valuable  collyrium  in  simple  conjunc- 
tivitis. A  I  per.  cent  solution  is  also  useful  in  ulcerative  stomatitis, 
cancrum  oris,  and  as  a  gargle  in  enlarged  tonsils  and  sore  throat. 

As  an  emetic  it  is  employed  in  narcotic  poisoning,  10-30  gr. 
(0.6-2.0  Gm.)  dissolved  in  water,  being  given  and  repeated  in  fifteen 
to  twenty  minutes,  if  necessary. 

Incompatibles. — Zinc  sulphate  is  incompatible  with  alkalies, 
alkaline  carbonates,  vegetable  astringents,  lead  acetate,  silver  nitrate, 
and  lime-water. 


82  ASTRINGENTS,    STYPTICS,    AND    HEMOSTATICS 

ZmCI  PHENOLSULPHONAS— U.S.P. 

(Zinc  Phenolsulphonate ;  Zinc  Sulphocarbolate ; 

Zn(C6H4(OH)S03)2.) 

Zinc  phenolsulphonate,  also  commonly,  though  erroneously, 
called  zinc  sulphocarbolate,  occurs  in  colorless,  transparent  prisms, 
or  tabular  crystals,  odorless,  and  having  an  astringent,  metallic  taste; 
on  exposure  to  air  and  Hght  it  effloresces  and  may  acquire  a  pink  tint. 
It  is  freely  soluble  in  water  and  alcohol.  The  aqueous  solution  is 
acid  to  litmus.  It  is  rarely  given  internally;  the  average  dose  is  2  gr. 
(0.125  Gm.). 

Physiologic  Action. — Zinc  phenolsulphonate  is  an  astringent  and 
antiseptic,  and  produces  a  stimulant  effect  upon  mucous  membranes. 
It  acts  similarly  to  other  zinc  salts,  but  the  contained  phenol  radical 
adds  to  its  antiseptic  power. 

Therapeutics. — This  salt  has  but  recently  been  employed  in 
dental  practice.  Whitslar  suggests  the  use  of  a  10  per  cent,  solution 
in  cinnamon  water  as  a  stimulating  antiseptic  following  the  surgery 
of  pyorrhea  alveolaris.  14  dr.  (2.0  Gm.)  added  to  8  oz.  (240.0  mils) 
of  hquor  antisepticus  makes  a  valuable  astringent  mouth-wash  to  be 
used  in  stomatitis  and  sore  throat. 

ZINCI  OXroUM— U.S.P. 
(Zinc  Oxid;  ZnO.) 

Zinc  oxid  is  a  fine,  white,  amorphous  powder,  without  odor  or 
taste.  Insoluble  in  water  or  alcohol.  It  is  rarely  used  internally, 
an  average  dose  being  4  gr.  (0.25  Gm.) .  There  is  one  official  prepara- 
tion : 

Unguentum  Zinci  Oxidi,  U.S. P.  (20  per  cent.). 

Physiologic  Action. — Zinc  oxid  is  a  mild  astringent  and 
antiseptic. 

Therapeutics.- — This  drug  has  been  used  extensively  as  a  vehicle 
for  making  pastes  of  liquids  for  treating  gangrenous  pulps  and  dento- 
aheolar  abscess,  also  for  root-canal  fillings.  In  the  light  of  our  pres- 
ent knowledge  of  ''focal  infection"  and  its  relation  to  systemic 
disease,  all  "pastes"  of  whatever  nature  should  be  discarded  for 
filling  root-canals.  Zinc  oxid  is  the  base  of  the  powder  for  all  zinc 
phosphate  cements. 

The  ointment  may  be  employed  to  soften  and  protect  the  mucous 
membrane  of  dry  and  cracked  lips  previous  to  operating  or  adjusting 
the  rubber  dam.     The  ointment  is  also  extensively  used  as  a  sHghtly 


ZINCI    lODIDUM — ZINCI    CHLORIDUM  St, 

astringent  and  protective  dressing  for  cold-sores,  burns,  acute  ulcers, 
and  acute  inflammatory  skin  diseases. 

ZINCI  lODEDUM  (Nonofficial) 
(Zinc  lodid;  Znl2.) 

Zinc  iodid  is  a  white,  granular  powder,  without  odor,  and  having 
a  sharp,  sahne,  and  metallic  taste.  It  is  a  very  deliquescent  salt  and 
liable  to  absorb  oxygen  from  the  air,  becoming  brown  from  liberated 
iodin.  Readily  soluble  in  water,  alcohol,  or  ether.  It  should  be 
kept  in  glass-stoppered  bottles.  When  used  internally  the  average 
dose  is  }/2  gr-  (0-03  Gm.). 

Physiologic  Action. — Zinc  iodid  is  astringent,  antiseptic,  and 
alterative. 

Therapeutics. — This  salt  may  be  used  as  a  mild  astringent,  anti- 
septic and  alterative  in  cases  of  ulcerative  stomatitis  and  pyorrhea 
aheolaris.  Talbot  suggests  using  the  following  remedy  in  cases  of 
flabby  and  inflamed  gums;  Zinc  iodid  15  parts,  water  10  parts,  iodin 
25  parts,  and  glycerin  40  parts.  The  salt  can  also  be  added  to  mouth- 
washes to  give  astringency  to  the  solution. 

ZINCI   CHLORIDUM— U.S.P. 

(Zinc  Chlorid;  ZnCla.) 

Zinc  chlorid  occurs  as  a  white,  granular  powder,  or  fused  mass, 
very  deliquescent,  odorless,  and  of  a  caustic,  metallic  taste.  //  is 
so  intensely  caustic  as  to  make  tasting  dangerous,  unless  the  salt  is 
dissolved  in  a  large  quantity  of  water,  in  which  it  is  freely  soluble; 
it  is  also  freely  soluble  in  alcohol.  It  is  not  used  internally.  The 
official  preparation  is : 

Liquor  Zinci  Chloridi,  U.S. P.  (50  per  cent.). 

Physiologic  Action.' — Zinc  chlorid  is  feebly  astringent  and  anti- 
septic. It  is  the  most  caustic  of  all  the  zinc  salts,  and  possesses 
marked  styptic  properties.  Its  prolonged  use  in  the  mouth  interferes 
with  the  secretory  action  of  the  salivary  glands  (Cook) . 

Therapeutics. — Solutions  of  zinc  chlorid  of  various  strengths  have 
enjoyed  an  unmerited  reputation  as  disinfectants  in  dental  practice. 
For  years  the  saturated  solution  has  been  mixed  with  zinc  oxid  to 
make  the  so-called  zinc  oxychlorid  cement,  and  used  for  filling  root- 
canals.  This  cement  is  not  used  to-day  to  any  great  extent  for  filling 
root-canals;  but  its  use  is  strongly  recommended  for  the  purpose  of 
covering  the  gutta-percha  canal  filling.     Webster  proved  the  material 


84         '  ASTRINGENTS,    STYPTICS,    AND   HEMOSTATICS 

to  be  impervious  to  bacteria,  which  is  a  distinct  advantage.  Black, 
Poundstone,  and  others  claim  this  is  not  true  of  the  ordinary  zinc 
phosphate  cements.  A  lo  per  cent,  solution  may  be  employed  for 
arresting  profuse  hemorrhage  in  pressure  anesthesia.  Applied  to 
sensitive  dentin  it  acts  as  an  obtundent.  Care  must  be  taken  not  to 
use  it  in  deep-seated  cavities  nearly  involving  the  pulp,  as  the  hy- 
drochloric acid  liberated  will  irritate  the  pulpal  organ.  This  irritant 
property  may  be  controlled  by  dissolving  the  salt  in  alcohol  and  then 
adding  chloroform.  A  formula  for  sensitive  dentin  follows:  Zinc 
chlorid  2q  gr.  (1.3  Gm.),  alcohol  and  chloroform,  of  each,  }^  fl.  oz. 
(15.0  mils).  The  drug  has  been  recommended  to  be  added  to  mouth- 
washes to  impart  astringency  to  the  solution.  Its  value  here  has 
been  overestimated,  for  it  is  the  least  astringent  of  all  zinc  salts,  and 
its  continued  use  in  the  mouth  changes  temporarily  the  character  of 
the  saliva. 

CALCn  CHLORroUM— U.S.P. 

(Calcium  Chlorid;  CaCla.) 

Calcitim  chlorid  occurs  in  white,  rather  translucent,  hard  frag- 
ments, is  very  deliquescent,  odorless,  and  of  an  acrid  saline  taste. 
It  is  freely  soluble  in  water,  somewhat  less  so  in  alcohol.  The  av- 
erage dose  is  8  gr.  (0.5  gm.). 

Physiologic  Action  and  Therapeutics. — Internally  administered 
calcium  chlorid  increases  the  coagulability  of  the  blood.  This  prop- 
erty was  first  mentioned  by  Wright,  of  England,  in  1893.  It  has 
been  used  with  success  in  hemophilia,  and  in  small  persistent  hemor- 
rhages, like  those  which  sometimes  follow  the  extraction  of  teeth. 

Wright  found  that  the  prolonged  administration  of  the  drug 
rather  decreases  than  increases  the  coagulability  of  the  blood,  and 
that  it  acts  best  as  a  hemostatic  by  giving  it  in  doses  of  from  3-10  gr. 
(0.2-0.6  Gm.)  three  times  a  day,  for  a  period  of  two  or  three  days,  and 
discontinuing  its  use  for  a  like  period.  The  drug  is  very  irritating  to 
the  stomach  and  should  be  given  after  meals,  well  diluted. 

BISMUTHI  SUBNITRA.S— U.S.P. 

(Bismuth  Subnitrate;  BiONOs  +  H20(?).) 

Bismuth  subnitrate  is  a  heavy  white  powder,  of  a  somewhat 
varying  chemic  composition,  odorless,  almost  tasteless,  and  slightly 
hygroscopic.  It  is  insoluble  in  water  and  alcohol,  but  soluble  in 
glycerin  in  about  12  parts  (Hereth).  The  average  dose  is  8 
gr.  (0.5  Gm.). 


ARGENTTIM — ^AUGENTI  NITEAS  85 

Physiologic  Action. — Upon  the  unbroken  skin  bismuth  subnitrate 
simply  acts  as  a  protective  agent;  but  upon  raw  surfaces  and  mucous 
membranes  it  also  acts  as  an  astringent  and  antiseptic.  From 
denuded  surfaces  absorption  of  the  drug  takes  place  rather  speedily, 
and  poisoning  has  been  known  to  occur  from  its  too  frequent  appli- 
cation. The  s3anptoms  of  bismuth  poisoning  are  stomatitis,  saHva- 
tion,  black  discoloration  of  th*  mucous  membrane  of  the  mouth, 
and  finally  ulceration  of  the  throat,  diarrhea  and  albumin  in  the 
urine.  Because  of  the  protection  the  insoluble  compound  affords 
to  the  part,  and  also  because  it  is  just  sufficiently  astringent  to  act 
as  a  stimulant  to  the  sluggish  cells,  this  drug  may  be  called  an  ideal 
antiseptic  when  applied  to  abraded  surfaces. 

Therapeutics.^Until  recently  bismuth  subnitrate  had  not  been 
employed  in  dentistry.  In  medicine  it  has  long  been  a  standard 
remedy  in  both  acute  and  chronic  gastric  catarrh  and  gastric  ulcer. 
Beck  has  recently  proved  its  value  in  chronic  tubercular  sinuses. 
The  drug  is  now  extensively  employed  in  dento-alveolar  sinuses, 
pyorrhea  pockets,  and  as  a  packing  for  wounds  after  surgical  opera- 
tions about  the  roots  of  teeth  and  the  alveolar  process.  The  formula 
for  Beck's  paste  is:  Bismuth  subnitrate  30  parts,  white  wax  and 
paraffin,  of  each  5  parts,  and  vaselin  60  parts.     Mix  with  heat. 

ARGENTUM  (Nonofficial) 

(Silver;  Ag.) 

Metallic  silver  is  used  extensively  in  dental  practice  in  the  form 
of  a  wire  for  suturing  fractured  jaws,  ligating  loose  teeth,  etc.  The 
most  important  salt  of  silver  used  in  dentistry  is  silver  nitrate, 
which  is  official. 

ARGENTI  NITEAS— U.S.P. 

(Silver  Nitrate;  AgNOs.) 

Silver  nitrate  occurs  in  colorless,  transparent,  tabular  crystals, 
odorless,  and  of  a  caustic  and  rather  metalHc  taste.  It  is  soluble 
in  about  0.4  part  of  water  and  in  30  parts  of  alcohol  at  25°C.  The 
salt  darkens  on  exposure  to  light,  and  should  be  kept  in  amber- 
colored  bottles.  The  average  dose  is  }/q  gr.  (o.oi  Gm.).  The  only 
official  preparation  is: 

Argenti  Nitras  Fusus,  U.S.P.,  Lunar  Caustic  (Silver  Nitrate 
fused  and  molded  into  hard  white  cones  or  pencils). 

Physiologic  Action. — While  silver  nitrate,  in  dilute  solution, 
acts  as  an  astringent  upon  mucous  membranes  and  raw  surfaces 


86  ASTEINGENTS,    STYPTICS,    AND    HEMOSTATICS 

in  that  it  contracts  the  tissues  to  which  it  is  applied  by  precipitating 
the  albumin  of  the  cells,  in  concentrated  solutions  or  crystal  form 
it  acts  as  an  unirritating  caustic,  coating  and  pro'tecting  the  parts 
with  white  silver  albuminate.  Much  investigation  has  been  done 
by  dentists  in  regard  to  the  depth  of  penetration  of  silver  nitrate, 
especially  when  applied  to  the  tooth-structure.  The  prevailing 
opinion  is  that  its  penetration  is#Umited  on  account  of  the  im- 
penetrable nature  of  the  coagulum  formed. 

In  weak  solutions  (1:2500),  silver  nitrate  is  active  as  a  disin- 
fectant. Internally  administered  in  medicinal  doses,  its  only  action 
is  that  of  an  astringent  and  antiseptic. 

The  long-continued  use  of  silver  nitrate,  even  when  locally  ap- 
plied, may  result  in  a  condition  known  as  argyria.  The  manifesta- 
tion of  this  condition  is  a  characteristic,  bluish-gray  discoloration 
of  the  skin  and  mucous  membranes.  As  a  rule,  it  does  not  interfere 
with  the  general  health,  but  the  discoloration  is  permanent. 

Therapeutics. — Silver  nitrate  is  a  valuable  therapeutic  agent 
in  dentistry,  being  used  largely  for  its  caustic  action.  It  is  chiefly 
employed  for  its  beneficent  effect  on  unnaturally  exposed  tooth- 
structure,  and  on  inflamed  mucous  membranes  and  ulcerjitive  surfaces. 
To  exposed  sensitive  cementum  it  may  be  applied  in  from  10  to  20 
per  cent,  solution,  the  part  first  being  dried;  or  the  surface  to  be 
cauterized  may  be  left  moist  and  the  soHd  stick  used.  Black  calls 
attention  to  the  fact  that  exposure  to  sunlight  aids  the  action  of 
the  salt.  In  the  absence  of  sunlight,  the  electric  mouth  lamp  will 
be  found  serviceable. 

This  drug  is  one  of  the  best  caustics  for  destroying  exuberant  and 
superfluous  granulations,  for  which  purpose  a  solution  may  be  used  up 
to  50  per  cent,  in  strength.  In  chronic  stomatitis  a  2  to  5  per  cent, 
solution  may  be  used  with  advantage;  the  pencils  may  be  used  in 
lightly  touching  mucous  patches.  Elliot  recommends  a  10  per  cent, 
solution  as  a  local  application  in  the  cracks  which  frequently  occur 
about  the  hands  and  feet.  It  is  stated  on  good  authority  that  there 
are  60,000  blind  people  in  the  United  States,  and  that  fuUy  one-third 
of  these  unfortunates  are  blind  because  of  a  disease  which  is  easily 
preventable.  This  is  known  scientifically  as  ophthalmia  neonatorum; 
but  mothers  and  midwives  simply  call  it  "baby  sore  eyes."  It  can 
be  prevented  by  dropping  a  few  minims  of  a  one  per  cent,  solution  of 
silver  nitrate  in  the  baby's  eyes  when  born.  Some  States  have  a  law 
making  it  obligatory  for  the  physician  in  attendance  at  birth  to  use  a 
solution  of  the  silver  compounds. 

P*recautions. — There  is  Httle  danger  of  producing  argyria  from 


SILVER  SALTS  AND  SOLUBLE  COMPOtOSTDS  87 

silver  nitrate  in  dental  practice,  yet  dentists  should  be  familiar  with 
this  condition.  In  using  the  drug,  care  should  be  taken  to  prevent 
the  cauterization  of  parts  not  intended,  as  the  patient's  lips,  gums, 
tongue,  buccal  mucous  membranes,  etc.  Sodium  chlorid  (common 
salt)  is  a  positive  antidote,  as  it  forms  with  the  drug  the  insoluble 
and  inert  silver  chlorid.  A  solution  of  the  antidote  should  always 
be  in  a  convenient  place  when  silver  nitrate  is  used  about  the  mouth . 
Incompatibles. — With  creosote  it  causes  an  explosion.  It  is 
also  incompatible  with  organic  matter  and  many  salts,  as  chlorid s, 
bromids,  iodids,  sulphids,  cyanids,  carbonates,  and  phosphates. 


OTHER  SILVER  SALTS  AND  SOLUBLE  COMPOUNDS 

An  effort  has  been  made  by  manufacturing  chemists  to  produce 
compounds  of  silver  which  possess  the  stimulant  and  disinfectant 
power  of  silver  nitrate  and  which  will  not  precipitate  albumin  or 
chlorids.  Some  of  these  preparations  have  proved  exceedingly 
valuable. 

Arg3n:ol  (Silver  Vitellin). — This  is  a  compound  of  a  derived  vege- 
table proteid  and  silver  oxid,  containing  from  20  to  25  per  cent,  of 
silver.  It  occurs  in  black,  glistening,  hygroscopic  scales,  freely 
soluble  in  water  and  glycerin,  insoluble  in  alcohol  and  oils. 

Physiologic  Action  and  Therapeutics. — In  strong  solutions  (20- 
50  per  cent.)  argyrol  is  claimed  to  be  nonirritating  to  mucous  mem- 
branes. It,  without  doubt,  possesses  marked  antiseptic  properties. 
It  is  recommended  in  nearly  all  diseased  conditions  of  the  mucous 
membranes;  as  in  stomatitis,  acute  ulcerous  gingivitis,  aphthous  sore 
mouth,  maxillary  sinusitis,  -pharyngitis,  and  conjunctivitis.  Brophy 
recommends  the  drug  in  the  after-treatment  of  antral  operations. 
It  is  used  in  from  10  to  50  per  cent,  solutions.  It  will  stain  the  skin 
and  mucous  membrane  as  well  as  the  clothing.  Care  should  be 
taken,  therefore,  in  using  the  drug  not  to  stain  the  latter.  Hot 
water  immediately  appUed  will  remove  the  stain  from  fabrics. 

Protargol. — This  is  a  proteid  compound  containing  about  8  per 
cent,  of  silver.  It  occurs  as  a  f§,wn-colored  powder,  freely  soluble  in 
water.  It  is  claimed  to  be  a  good  disinfectant,  and  comparatively 
free  from  irritant  properties.  Its  action  is  similar  to  that  of  argyrol, 
and  it  is  used  for  practically  the  same  pathologic  conditions.  The 
extreme  solubility  of  argyrol  and  the  high  percentage  of  silver  which 
it  contains  have  caused  this  drug  to  largely  supersede  protargol  in 
dental  practice. 


8b  BLEACHERS 

Silver  Preparations,  Colloidal. — Under  certain  conditions  involv- 
ing a  very  fine  state  of  subdivision,  metallic  silver  and  some  of  its 
compounds  ordinarily  insoluble  become  capable  of  colloidal  suspen- 
sion, forming  with  water  mixtures  closely  resembling  solutions. 
These  preparations  are  not  precipitated  by  the  ordinary  precipitants 
of  silver  salts.  As  a  result  they  can  be  mixed  with  organic  liquids  or 
injected  into  tissues  or  even  into  the  blood-stream  without  precipita- 
tion and  without  causing  marked  symptoms  of  irritation.  They 
possess  to  a  greater  or  less  degree  the  antiseptic  properties  of  solu- 
tions of  silver  compounds.  Several  similar  preparations  of  this  kind 
are  on  the  market  and  are  variously  known  as  cargentos,  collargol, 
eleclrargol. 

BLEACHERS 

Bleachers,  or  bleaching  agents,  have  been  defined  as  agents 
used  to  restore  the  color  of  tooth-structure.  The  methods  employed 
in  bleaching  teeth  will  be  described  in  detail  later  in  this  work. 
It  is  intended  here  to  discuss  only  the  drugs  used  for  this  purpose. 
However,  it  is  important  that  the  student  should  know  that  the 
methods  of  bleaching  teeth  involve  more  or  less  of  chemistry.  The 
general  principle  of  bleaching  teeth  is  to  chemically  change  the  insolu- 
ble colored  pigment  into  a  soluble  compound  so  that  it  may  be  washed 
out  of  the  tooth-structure,  or  else  chemically  attack  the  pigment 
in  such  a  way  as  to  break  up  its  molecular  arrangement  and  thus 
destroy  its  color.  This  may  be  accompHshed  by  one  of  two  general 
chemic  processes — oxidation  or  reduction.  The  agents  used  for 
bleaching  teeth,  therefore,  can  be  divided  into  two  classes:  Those 
which  oxidize  and  those  which  reduce  the  pigment. 

OXIDIZING  AGENTS 

This  class  of  drugs  may  also  be  conveniently  subdivided  into  two 
classes — direct  and  indirect  oxidizing  agents.  The  former  is  any 
agent  from  which  oxygen  may  be  obtained  directly,  and  the  latter  is 
any  agent  from  which  oxygen  may  be  obtained  indirectly. 

The  direct  oxidizing  agents  used  for  bleaching  teeth  are : 

Sodium  Dioxjd.  Acetozone. 

Hydrogen  Dioxid.*  Alphozone. 

Oxalic  Acid. 

There  is  only  one  indirect  oxidizing  agent  used  and  that  is: 

Chlorin. 


SODII  DioxmuM  89 

SODH  DIOXmUM  (Nonofficial) 
(Sodium  Peroxid;  Na202.) 

Sodimn  dioxid  occurs  as  a  light  yellow,  more  or  less  granular 
powder.  It  is  the  sodium  salt  of  hydrogen  dioxid  containing  at 
least  90  per  cent.  Na202,  equivalent  to  18.4  per  cent,  available 
oxygen.  It  is  chemically  soluble  in  water,  and  insoluble  in  absolute 
alcohol  and  chloroform.  It  readily  absorbs  moisture  from  the  air, 
thus  deteriorating,  and  is  best  kept  in  tightly  covered  tin  cans.  The 
drug  is  never  given  internally. 

Action.— To  speak  of  the  physiologic  action  of  sodium  dioxid 
would  be  incorrect,  for  it  is  such  a  violent  caustic  when  applied  to 
live  tissue  that  its  action  cannot  be  confined  within  physiologic  Kmits. 
It  is,  therefore,  rarely  used  in  medicine.  As  a  direct  oxidizing  agent 
for  bleaching  teeth,  where  its  action  can  be  confined  to  the  tooth- 
structure,  it  has  no  equal;  especially  is  this  true  when  the  sodium 
dioxid  is  decomposed  by  water,  which  Hberating  nascent  oxygen  forms 
sodium  hydroxid  as  a  by-product.  The  nascent  oxygen  attacks  the 
pigment  which  has  stained  the  tooth,  and  the  sodium  hydroxid  at- 
tacks any  fatty  substances  which  may  be  present,  forming  therewith 
a  soluble  soap.  This  double  action  of  sodium  dioxid,  when  decom- 
posed by  water,  gives  to  the  agent  its  great  advantage  as  a  bleaching 
agent.  The  drug  may  be  decomposed  by  acids  with  the  Hberation  of 
nascent  oxygen,  but  by  this  means  the  valuable  by-product  (sodium 
hydroxid)  is  destroyed.  Used  in  this  way,  then,  sodium  dioxid  has  no 
advantage  over  any  other  agent  which  liberates  an  equal  volume  of 
oxygen.  It  is  a  fact  long  recognized  by  those  engaged  in  the  bleach- 
ing of  hair,  feathers,  wool,  broom-corn,  ivory,  bone,  etc.,  that  the 
bleaching  process  is  favored  when  carried  on  in  an  alkaline  medium. 
This  is  likewise  true  in  bleaching  teeth. 

Therapeutics. — In  dental  practice,  where  the  violent  caustic 
properties  of  sodium  dioxid  can  be  confined  to  the  tooth-structure, 
this  agent  has  a  rather  wide  range  of  usefulness.  Both  the  powder 
and  a  solution  made  by  carefully  adding  the  powder  to  cold  water  are 
used. 

There  are  two  important  reactions  which  take  place  when  sodium 
dioxid  is  added  to  water,  and  it  is  well  to  explain  these  here.  If  the 
powder  is  added  to  water  in  small  quantities,  care  being  taken  to  keep 
down  the  temperature  with  ice  or  cold  water,  a  reaction  takes  place 
which  results  in  a  solution  containing  hydrogen  dioxid  and  sodium 
hydroxid.  This  solution  freshly  prepared  may  be  used  for  bleaching 
teeth.     The  hydrogen  dioxid  will  liberate  oxygen  which  does  the 


90  BLEACHERS 

bleaching  and  the  sodium  hydroxid  creates  an  alkaline  medium  which 
favors  the  bleaching  process ;  it  also  acts  to  advantage  upon  any  fats 
which  may  be  present.  The  great  difficulty  here  is  in  obtaining  the 
solution  fresh,  as  the  sodium  hydroxid  gradually  decomposes  the  hy- 
drogen dioxid  into  water  and  oxygen,  the  latter  gas  being  lost.  If 
sodium  dioxid  is  added  to  water  without  any  precaution  as  to  lower- 
ing the  temperature,  a  somewhat  different  reaction  takes  place.  Here 
the  drug  is  at  once  decomposed  into  oxygen  and  sodium  hydroxid. 
For  all  dental  purposes  this  is  the  best  way  to  use  the  drug,  viz. :  Place 
the  powder  in  the  cavity  or  canal  of  the  tooth  and  decompose  it 
into  oxygen  and  sodium  hydroxid  by  adding  distilled  water.  In  this 
way  it  may  be  used  for  bleaching  teeth,  disorganizing  remnants  of  pulp 
tissue,  and  enlarging  tortuous  root-canals.  For  the  latter  purposes  the 
use  of  the  drug  should  alternate  with  a  30  per  cent,  solution  of  sul- 
phuric acid.  Though  not  employed  to  any  extent  in  medicine,  the 
drug  has  been  used  in  acne,  applied  in  the  form  of  a  paste  prepared 
with  liquid  paraffin,  or  as  a  soap  to  remove  comedones.  It  has  been 
suggested  as  an  air  purifier;  this  suggestion  being  based  on  the  theory 
that  the  moisture  of  the  air  would  decompose  the  chemical  gradually,' 
thus  Hberating  oxygen  and  forming  the  alkali,  sodium  hydroxid, 
which  absorbs  carbon  dioxid.  The  theory  is  correct,  but  it  is  doubt- 
ful if  the  drug  could  be  used  to  any  practical  advantage,  except,  per- 
haps, on  a  Hmited  scale. 

Incompatibles. — Sodium  dioxid  will  produce  a  pyrotechnic 
display  with  many  of  the  volatile  oils,  ether  and  phenol.  It  is  decom- 
posed by  water  and  acids. 

HYDROGEN  DIOXID 

The  direct  oxidizing  agent  has  been  fully  discussed  under  the 
heading  of  Disinfectants.  'The  official  3  per  cent,  solution  is  some- 
times concentrated  or  used  with  other  drugs  for  bleaching  purposes. 
As  a  bleacher  this  solution  has  largely  been  superseded  by  the  com- 
mercial preparation  called  "caustic  pyrozone,"  which  is  a  25  per  cent, 
ethereal  solution  of  pure  hydrogen  dioxid.  Like  all  direct  oxidizers, 
its  value  depends  upon  the  nascent  oxygen  which  it  Hberates.  For 
bleaching  teeth  better  results  are  produced  when  the  tooth-structure 
has  been  previously  moistened  with  a  weak  alkaline  solution,  such  as 
lime-water. 

ACETOZONE  (Nonofficial) 

(Benzoylacetyl  Dioxid;  CeHgCOO.O.COCHs.  =  CgHsO*.) 

Acetozone,  or  benzoylacetyl  dioxid,  is  made  by  the  oxidation 
of  a  mixture  of  benzaldehyd  and  acetic  anhydrid.     It  occurs  as  a 


ALPHOZONE  91 

white,  shining  crystalline  powder.  Slightly  soluble  in  water,  alcohol, 
and  fairly  so  in  ether  and  chloroform.  In  oils  it  is  soluble  to  the  ex- 
tent of  about  3  per  cent.  All  solvents  slowly  decompose  the  drug 
with  the  exception  of  neutral  petroleum  oils.  Not  used  internally  in 
dentistry. 

Action  and  Uses. — Acetozone  belongs  to  a  class  of  compounds 
known  as  the  organic  dioxids  or  peroxids  in  which  an  excess  of  oxygen 
has  been  combined  in  such  a  way  that  it  is  slowly  given  off  in  the 
nascent  state.  In  the  presence  of  water  it  hydrolyzes,  forming  ben- 
zoperacid  and  aceto-peracid  which  exert  marked  oxidizing  and  disin- 
fectant action.  Acetozone  is  used  in  dentistry  as  a  bleaching  agent. 
Hoff  recommends  placing  the  powder  in  the  cavity  of  the  tooth  to  he 
bleached,  moisten  with  water  to  bring  about  the  hydrolysis,  and  her- 
metically seal.  It  is  claimed  to  be  useful  as  an  antiseptic  in  ophthal- 
mic, aural  and  nasal  practice,  and  to  give  good  results  by  acting  as 
an  intestinal  antiseptic  when  given  internally,  especially  in  typhoid 
fever. 


ALPHOZONE  (Nonofficial) 
(Succinic  Dioxid  (COOH.CH2.CH2.CO)202  =  CgHioOg.) 

Alphozone,  or  succinic  dioxid,  is  an  organic  dioxid,  or  peroxid, 
resulting  from  the  condensation  of  hydrogen  dioxid  with  succinic 
anhydrid.  It  occurs  as  a  fluffy,  white,  crystalline  powder.  Soluble 
in  30  parts  of  water  at  ordinary  temperature;  moderately  soluble  in 
alcohol,  sparingly  so  in  ether,  and  insoluble  in  chloroform.  It  should 
be  kept  in  a  dark  place  and  in  tightly  stoppered  bottles.  Not  used 
internally  in  dentistry. 

Action  and  Uses. — Alphozone  is  a  powerful  oxidizer,  and  thus 
becomes  an  antiseptic,  disinfectant,  and  deodorant.  It  possesses 
marked  bleaching  properties.  It  is  claimed  to  possess  an  advantage 
over  hydrogen  dioxid  as  a  therapeutic  agent  in  that  it  does  not 
effervesce  with  pus  nor  in  contact  with  Hving  tissues.  Alphozone 
may  be  used  for  bleaching  teeth  in  the  same  manner  as  acetozone. 
Water  does  not  decompose  the  drug.  It  may  also  be  employed 
for  disinfecting  the  hands  and  such  instruments  as  are  not  attacked 
by  oxidizing  agents.  The  drug  can  be  obtained  in  the  powder  form 
or  in  tablets  containing  i  gr.  (0.065  Gm.)  each,  which  is  used  for 
making  solutions  for  external  use.  One  tablet  to  2  fl.  oz.  (60.0  mils) 
makes  a  suitable  disinfectant  solution  for  general  use. 


92  BLEACHERS 

ACIDUM  OXALICUM  (Nonofficial) 
(OxaUc  Acid;  H2C2O4  +  H2O.) 

Oxalic  acid  occurs  in  the  form  of  transparent,  prismatic  crystals, 
is  odorless,  and  of  a  very  acid  taste.  It  is  readily  soluble  in  water 
and  alcohol.     Not  used  internally  in  dentistry. 

Action  and  Uses. — OxaHc  acid  is  a  direct  oxidizer.  As  a  bleach- 
ing agent  for  teeth  its  power  is  limited.  Kelley  and  others  have 
recommended  it  as  a  disinfectant  for  the  hands. 

CHLORUM  (Nonofficial) 
(Chlorin;  CI.) 

Chlorin  is  a  heavy,  yellowish-green  gas,  of  a  very  suffocating  odor 
and  a  caustic  taste.  It  may  be  prepared  by  acting  upon  chlorinated 
lime  with  an  acid.     The  gas  is  soluble  in  water. 

Action  and  Uses. — Chlorin  is  a  powerful  irritant.  When  inhaled 
it  causes  inflammation,  and,  at  times,  edema  of  the  lungs.  It  has 
such  a  great  afi&nity  for  hydrogen  that  it  will  abstract  this  element 
from  a  molecule  of  water,  liberating  the  oxygen  in  the  nascent  state.' 
Because  of  this  fact  it  is  an  indirect  oxidizing  agent,  and  its  bleach- 
ing ability  as  well  as  its  disinfectant  power  depends  upon  this 
property.  About  the  only  use  made  of  chlorin  in  dental  practice 
is  as  a  bleaching  agent.  It  bleaches  indirectly.  For  bleaching  teeth^ 
compounds  and  preparations  of  chlorin,  from  which  the  gas  is 
liberated,  are  used. 

CALX  CHLORINATA— U.S.P. 

(Chlorinated  Lime;  CaOCl  +  CaCl2.) 

Chlorinated  lime  is  a  mixture  of  calcium  hypochlorite  and 
calcium  chlorid.  It  is  prepared  by  acting  upon  slaked  Ume  with 
chlorin  gas,  and  should  contain  not  less  than  30  per  cent,  of  available 
chlorin.  It  occurs  as  a  grayish-white  powder,  having  a  strong  odor 
of  chlorin  and  a  disagreeable  saHne  taste.  It  is  partially  soluble  in 
water  and  alcohol. 

Action  and  Uses. — As  the  mixture  constantly  Uberates  chlorin 
gas,  it  is  a  disinfectant  and  bleacher.  It  is  used  in  dentistry  as  a 
means  of  obtaining  chlorin  for  bleaching  teeth. 

LIQUOR  ^ODM  CHLORINATE— U.S.P. 

(Solution  of  Chlorinated  Soda;  Labarraque's  Solution.) 

This  is  a  solution  of  several  chlorin  compounds  of  sodium  con- 
taining not  less  than  2.5  per  cent,  by  weight  of  available  chlorin. 


ACIDUM  SULPHUROSUM  93 

Action  and  Uses. — Solution  of  chlorinated  soda  is  a  disinfectant, 
deodorant  and  bleacher.  Like  chlorinated  lime,  it  is  used  in  dentistry 
as  a  means  of  obtaining  chlorin  for  bleaching  teeth.  The  solution 
should  be  freshly  prepared. 

REDUCING   AGENTS 

These  are  agents  which  have  the  power  of  abstracting  oxygen 
from  a  compound  containing  it.  The  process  is  called  reduction  or 
deoxidation. 

There  is  only  one  reducing  agent  used  for  bleaching  teeth.  That 
is  sulphurous  acid. 

ACmUM  SULPHUROSUM  (Nonofficial) 
(Sulphurous  Acid;  H2SO3.) 

Sulphurous  acid  is  generally  used  in  the  form  of  a  6  per  cent. 
aqueous  solution  of  sulphur  dioxid.  This  was  the  official  solution 
of  the  U.S.P.  VIII. 

Action  and  Uses. — Sulphur  dioxid  is  a  gas  which  chemically 
dissolves  in  water  and  forms  sulphurous  acid.  This  acid  has  a  great 
affinity  for  oxygen,  and  absorbs  the  latter  gas  from  the  air  or  abstracts 
it  from  compounds  containing  it,  thus  reducing  the  compound  and 
forming  sulphuric  acid. 

For  bleaching  teeth  it  is  best  to  use  a  mixture  of  such  compounds 
as,  when  dissolved,  will  react  upon  each  other  and  produce  sulphur 
dioxid  within  the  tooth  to  be  bleached.  The  gas  unites  with  the 
water  present,  forming  sulphurous  acid,  which  has  a  tendency  to 
abstract  oxygen  from  the  colored  pigment  which  has  stained  the 
tooth,  and  thus  the  rearrangement  of  the  elements  of  the  colored 
molecule  destroys  its  color.  Kirk  suggests  using  a  mixture  of  10 
parts  of  sodium  sulphite  and  7  parts  of  boric  acid.  This  mixture 
may  be  packed  into  the  cavity  of  the  tooth,  moistened  with  water, 
and  hermetically  sealed.  The  tooth  should  subsequently  be  washed . 
with  an  alkahne  solution  to  neutralize  the  acid  formed. 

ESCHAROTICS  OR  CAUSTICS 

Escharotics  or  caustics  are  agents  which  destroy  the  tissue 
upon  which  they  act.  While  the  action  of  this  class  of  drugs  varies 
with  the  drug  employed,  it  may  be  stated  in  general  that  their 
action  is  purely  chemic  or  physico-chemic.  Many  of  them  have  an 
immediate  chemic  action  upon  the  tissues,  and  are  sometimes  called 
corrosives.     Nearly  all  escharotics  produce  an  eschar,  the  character 


94  ESCHAROTICS    OR   CAUSTICS 

of  which  depends  largely  upon  the  tissue  involved.  This  eschar  is 
ultimately  separated  from  the  living  tissues  by  the  inflammatory 
process  thus  inaugurated.  Some  of  the  agents  belonging  to  this 
class  are  quite  readily  absorbed,  and  may  cause  systemic  poisoning. 
The  compounds  of  arsenic — especially  arsenic  trioxid,  long  used  in 
dentistry  for  devitalizing  the  pulps  of  teeth — are  of  this  character, 
as  they  have  a  specific  poisonous  action  upon  the  cells.  The  salts 
of  chromium  and  osmium  may  also  be  mentioned  in  this  connec- 
tion. The  strong  mineral  acids  abstract  water  from  the  tissues  and 
precipitate  the  proteids;  the  alkaline  hydrates,  on  the  other  hand, 
not  only  abstract  water  but  dissolve  the  proteids  and  form  with 
them  soluble  compounds. 
The  chief  escharotics  are: 

Mineral  Acids:  Arsenic  Trioxid. 

Sulphuric  Acid.  Chromium  Trioxid. 

Nitric  Acid.  Osmic  Acid. 

Hydrochloric  Acid.  Potassium  Hydroxid. 

Phenol.*  Sodium  Hydroxid. 

Acetic  Acid.  Zinc  Chlorid.* 

Trichloracetic  Acid.  Mercuric  Chlorid.* 

Monochloracetic  Acid.  Silver  Nitrate.* 

Lactic  Acid.  Actual  Cautery. 

Several  of  the  above  escharotics  have  been  considered  elsewhere. 
Those  which  have  not  will  here  be  discussed  in  detail. 

ACmUM  SULPHURICUM— U.S.P. 

(Sulphuric  Acid;  Oil  of  Vitriol;  H2SO4.) 

Sulphuric  acid  is  a  colorless,  heavy,  oily  liquid,  without  odor, 
and  of  an  extremely  sour  taste  and  acid  reaction.  It  is  miscible  with 
water  and  alcohol  in  all  proportions  with  the  evolution  of  heat.  A 
precaution  to  be  remembered  is  that,  in  diluting,  the  acid  should  be 
added  to  the  water  or  other  diluent,  and  not  the  reverse.  The  acid  is 
not  used  internally  in  dentistry.     The  official  preparations  are: 

Acidum  Sulphuricum  Dilutum,  U.S. P.  (Contains  10  per 
cent,  of  absolute  Sulphuric  Acid.) 

Acidum  Sulphuricum  Aromaticum,  U.S. P.  (Contains 
about  10  per  cent,  of  Sulphuric  Acid  in  Alcohol  with  the  addi- 
tion of  such  aromatics  as  Ginger  and  Cinnamon.) 

Phenolsulphonic  acid  (HC6H3(HS03)20)  is  prepared  from  phenol 
and  chemically  pure  sulphuric  acid.  It  occurs  as  a  faint  reddish- 
colored,  heavy,  syrupy  liquid,  of  a  rather  phenol-like  odor  and  a  char- 
acteristic acid  taste  and  reaction.  It  unites  with  some  metals  to  form 


ACIDUM  SULPHURICUM  95 

salts,  notably  zinc.  It  is  rather  difficult  to  combine  phenol  and  sul- 
phuric acid  so  that  the  resultant  mixture  may  be  diluted  with  water 
without  separation  of  the  original  constituents.  Inasmuch  as  the 
concentrated  phenolsulphonic  acid  is  rarely  used  in  dentistry,  direc- 
tions here  follow  for  preparing  it  so  that  any  dilution  may  be  made: 
Ninety- seven  parts  by  weight  of  pure  concentrated  sulphuric  add 
are  gradually  added  to  93  parts  by  weight  of  pure  phenol  and  the 
mixture  kept  at  a  temperature  of  about  ioo°C.  for  about  twenty 
hours,  until  only  a  small  percentage  of  sulphuric  acid  remains  uncom- 
bined.  When  the  reaction  is  thus  complete,  sufficient  distilled  water 
is  added  to  make  the  finished  product  assay  about  80  per  cent,  phenol- 
sulphonic acid.  This  Hquid  is  miscible  with  water  in  all  proportions; 
and  whenever  phenolsulphonic  acid  is  mentioned  in  these  pages  this 
product  is  meant.  It  should  not  be  confused  with  the  preparation 
suggested  by  Cook,  of  Chicago,  which  is  a  heavy,  oily,  dark  brown 
liquid  made  by  mixing  crude  sulphuric  acid  and  crude  phenol,  and 
which  can  only  be  used  in  full  strength,  as  water  causes  a  separation 
of  the  constituents. 

Physiologic  Action. — When  applied  to  the  skin,  accidentally  or 
otherwise,  sulphuric  acid  in  concentrated  form  causes  an  intense, 
burning  pain,  and  results  in  a  rapid  destruction  of  tissue.  The  eschar 
is  at  first  white,  gradually  becoming  brown.  The  corrosive  effect 
upon  mucous  membranes  is  stiU  more  marked  than  upon  the  skin. 
The  acid  rapidly  extracts  water  from  the  tissue,  the  alkalies  are  neu- 
trahzed,  and  the  proteids  precipitated;  this  results  in  the  complete 
destruction  of  the  tissue  (dissolution) .  When  taken  internally  large 
doses  cause  burning  in  the  throat  and  esophagus,  violent  pain  in  the 
abdomen,  constant  vomiting  of  dark  matter,  mixed  with  blood  and 
mucus,  difficult  breathing,  and  ultimate  collapse. 

Therapeutics. — Sulphuric  acid  is  used  in  dentistry  more  than  any 
of  the  other  mineral  acids.  Because  of  its  violent  action  upon  soft 
tissue,  it  is  seldom  used  as  an  escharotic  except  at  times  on  pulp  tissue 
where  its  action  can  be  controlled.  By  many  it  is  used  in  30  per  cent, 
solution  to  neutralize  the  contents  of  gangrenous  root-canals,  and  for 
enlarging  fine  and  tortuous  canals.  This  is  known  as  the  Callahan 
method.  It  may  also  be  employed  to  destroy  a  remnant  oj  a  ptdp 
in  the  apical  end  of  a  root,  and  for  dislodging  pulp  nodules  in  the 
pulp-chambers  and  root-canals  of  teeth.  A  10  per  cent,  solution 
may  be  cautiously  used  for  steriHzing  the  dentin  and  opening  the 
tubules  previous  to  removing  a  pulp  by  pressure  anesthesia  or 
bleaching  the  tooth-structure.  Care  must  always  be  exercised  in  the 
use  of  sulphuric  acid,  even  in  weak  solutions,  not  to  get  the  agent  on 


96  ESCHAROTICS    OR   CAUSTICS 

the  enamel  of  the  crown  of  the  tooth  or  soft  tissues  of  the  mouth.  '  It 
should  be  remembered  here  that  a  weak  solution  of  an  alkaline  salt, 
such  as  sodium  bicarbonate,  will  at  once  neutraHze  the  action  of  all 
mineral  acids,  and  such  a  solution  should  be  ready  to  use  when  these 
agents  are  employed.  Perhaps  the  most  useful  combination  of  sul- 
phuric acid  in  dental  practice  is  phenolsul phonic  acid.  This  agent 
may  be  used  in  nearly  every  instance  where  sulphuric  acid  is  indi- 
cated and  often  to  advantage.  The  author  especially  recommends 
its  use  following  the  initial  dressing  of  formocresol  in  cases  of  gangren- 
ous pulps  and  dental  granulomas.  In  caries  or  necrosis  of  bone,  in 
chronic  •  alveolar  abscess,  and  pyorrhea  alveolaris,  where  the  "acid 
treatment"  is  indicated,  phenolsulphonic  acid,  properly  employed, 
will  give  beneficial  results. 

Incompatibles. — Sulphuric  acid  is  incompatible  with  alkalies, 
alkahne  carbonates,  iodids,  and  certain  salts  of  lead.  It  is  explosive 
with  oil  of  turpentine  and  sugar,  and  carbonizes  syrups  because  of  the 
sugar  therein  contained. 

ACEDUM  NITRICUM— U.S.P. 

(Nitric  Acid;  Aqua  Fortis;  HNO3.) 

Nitric  acid  is  a  strongly  corrosive,  fuming,  caustic  liquid,  com- 
posed of  68  per  cent,  absolute  nitric  acid  and  32  per  cent,  of  water 
with  which  Hquid  it  is  miscible  in  all  proportions.  It  reacts  explo- 
sively with  alcohol  and  glycerin,  and  is  not  used  internally  in  den- 
tistry.    The  official  preparations  are: 

Acidum  Nitrohydrochloricum,  U.S. P.  (Aqua  Regia;  Nitric 
Acid  18  vols.;  Hydrochloric  Acid  82  vols.). 
Acidum    Nitrohydrochloricum    Dilutum,   U.S. P.     (Nitric 
Acid,  lo.o  mils;   Hydrochloric  Acid,  45.5   mils;   Distilled 
Water,  194.5  mils). 

Physiologic  Action  and  Therapeutics.— Nitric  acid,  though  a 
powerful  escharotic,  is  not  as  penetrating  or  painful  as  sulphuric  acid. 
It  produces  a  characteristic  yellow  stain  on  the  skin  and  mucous 
membrane.  In  large  doses  it  causes  practically  the  same  train  of 
symptoms  as  sulphuric  acid,  except  that  the  discoloration  is  yellow 
instead  of  white  and  then  brown.  The  acid  is  not  used  to  any  extent 
in  dental  practice.  It  may  be  applied  to  warts  and  other  fungous 
growths,  and  has  proved  to  be  a  reliable  agent  in  phagedenic  ulcers, 
chancroids  and  chancres. 

Incompatibles. — This  acid  is  incompatible  with  alkalies,  alkaline 
carbonates,  oxids,  lead  acetate,  and  iron  sulphate.  It  explodes  with 
such  agents  as  alcohol,  glycerin,  phenol,  and  volatile  oils. 


ACmUM  HYDROCHLOE.ICUM — ^ACIDXJM  ACETICUM  97 

ACmUM  HYDROCHLORICUM— U.S.P. 

(Hydrochloric  Acid;  Muriatic  Acid;  HCl.) 

Hydrochloric  acid  is  a  fuming,  corrosive  liquid,  consisting  of 
about  32  per  cent,  of  absolute  hydrochloric  acid.  It  is  miscible  with 
water  and  alcohol  in  all  proportions.  It  is  not  used  internally  in 
dentistry.     The  ofi&cial  preparation  is: 

Acidum  Hydrochloricum  Dilutum,  U.S. P.  (10  per  cent,  by 
weight.) 

Physiologic  Action  and  Therapeutics. — The  action  of  hydro- 
chloric acid  closely  resembles  that  of  the  other  mineral  acids.  As  a 
therapeutic  agent  the  strong  acid  is  not  used  to  any  extent  in  dentis- 
try. It  is  chiefly  used  to  prepare  the  diluted  and  other  acids.  Di- 
lute hydrochloric  acid  has  been  used  by  Andrew  and  Morris  for  the 
removal  of  sequestra,  and  necrosed  bone  in  osteitis  and  caries.  It  is 
inferior  to  phenolsulphonic  acid  for  these  purposes. 

Incompatibles.' — The  acid  is  incompatible  with  alkalies,  car- 
bonates, and  silver  nitrate. 

Treatment  of  Poisoning  by  Mineral  Acids. — The  treatment  of 
poisoning  by  the  mineral  acids  to  be  effective  should  be  prompt. 
The  cautious  administration  of  alkalies  is  indicated  to  chemically 
neutralize  the  acid.  Lime-water,  magnesia,  and  soap  are  best. 
Carbonates  must  be  used  with  care,  if  at  all,  on  account  of  the  lia- 
bihty  to  rupture  the  stomach  from  the  evolution  of  carbon  dioxid  (a 
gas).  Stevens  cautions  against  the  use  of  the  stomach-pump  on 
account  of  the  risk  of  piercing  the  softened  esophagus.  After  the 
acid  is  neutralized  with  the  alkaline  solutions,  demulcent  drinks, 
such  as  albumin- water,  milk  and  raw  eggs,  should  be  given  to  soothe 
the  parts.  To  control  the  pain,  opium,  or  its  alkaloids,  are  indi- 
cated, and  whisky  or  brandy  should  be  injected  subcutaneously  in 
case  of  collapse. 

ACIDUM  ACETICUM— U.S.P. 
(Acetic  Acid;  HC2H3O2.) 

Acetic  acid  is  a  liquid  composed  of  36  per  cent,  by  weight  of 
absolute  acetic  acid  and  64  per  cent,  of  water.  It  occurs  as  a 
clear,  colorless  Hquid,  having  a  strong,  vinegar-like  odor,  and  a 
purely  acid  taste.  Miscible  with  water  and  alcohol  in  all  propor- 
tions.    The  average  dose  of  the  diluted  acid  is  30  min.  (2.0  mils). 


98  ESCHAROTICS    OH   CAUSTICS 

The  ofificial  preparations  are : 

Acidum  Aceticum  Dilutum,  U.S. P.  (6  per  cent,  by  weight  of 
absolute  Acetic  Acid). 

Acidum  Aceticum  Glaciale,  U.S. P.  (Glacial  Acetic  Acid;  99 
per  cent,  absolute  Acid). 

Physiologic  Action. — The  concentrated  acetic  acid  when  appKed 
locally  produces  redness,  vesication,  and  ultimately  slight  sloughing. 
Internally  it  causes  severe  gastritis. 

Therapeutics. — Acetic  acid  is  applied  externally  to  indolent 
ulcers  of  the  mouth  and  canker  sores.  A  weak  solution  may  be  used 
as  a  gargle  in  cases  of  pharyngitis  or  sore  throat.  Glacial  acetic  acid 
may  be  applied  to  fungous  growths  in  the  mouth.  It  is  also  used  to 
remove  warts  and  corns.  The  dilute  acid  or  vinegar  is  especially 
indicated  as  an  antidote  in  cases  of  poisoning  by  alkalies.  The 
quantity  to  be  given  must  be  governed  largely  by  the  probable 
amount  of  alkali  to  be  neutralized.  In  bleaching  teeth  with  sodium 
dioxid,  or  in  using  the  caustic  alkalies  about  the  teeth,  a  weak  solu- 
tion of  acetic  acid  should  be  at  hand  to  neutralize  any  alkali  which 
may  get  on  the  soft  tissues  of  the  mouth. 

ACmUM  TRICHLORACETICUM— U.S.P. 

(Trichloracetic  Acid;  HC2CI3O2.) 

Trichloracetic  acid  occurs  as  white,  deliquescent  crystals,  freely 
soluble  in  water,  alcohol,  and  ether.  It  is  made  by  acting  on  glacial 
acetic  acid  with  chlorin  or  on  hydrated  chloral  with  fuming  nitric 
acid. 

Physiologic  Action  and  Therapeutics. — Trichloracetic  acid  acts 
as  an  escharotic,  astringent,  and  hemostatic.  A  solution  of  5  to 
10  per  cent,  may  be  applied  to  indolent  ulcers,  mucous  patches,  etc. 
A  10  to  20  per  cent,  solution  is  an  excellent  stimulating  agent  to 
be  forced  through  a  sinus  in  chronic  alveolar  abscess  and  into  a 
stubborn  pyorrheal  pocket.  It  may  also  be  employed  in  this  strength 
solution  as  a  hemostatic  in  case  of  profuse  hemorrhage  after  the 
removal  of  a  pulp  by  pressure  anesthesia.  The  pure  drug  or  a 
concentrated  solution  has  been  employed  to  some  extent  for  the 
removal  of  small  growths  about  the  mouth,  such  as  hy pertro phied 
gum  or  pulp  tissue.  The  agent  is  also  used  for  the  removal  of  warts 
and  corns. 

Monochloracetic  Acid. — (HC2H2CIO2). — This  agent  occurs  as  a 
white  crystalline  substance,  soluble  in  water  and  alcohol.  As 
shown  by  the  formula,  only  one  of  the  hydrogen  atoms  in  glacial 


ACiDi:::^!  lacticum — ^arseni  xRioxrouM  99 

acetic  acid  is  displaced  by  chlorin.  Harlan  recommended  the  use 
of  this  agent  in  the  treatment  of  gangrenous  canals  of  teeth.  The 
remedy  never  gained  any  favor,  as  its  action  is  uncertain. 

ACmUM  LACTICUM— U.S.P. 

(Lactic  Acid;  HC3H5O3.) 

Lactic  acid  is  an  organic  acid  usually  obtained  by  the  fermenta- 
tion of  grape-sugar  or  milk-sugar.  The  ofi&cial  preparation  is  com- 
posed of  not  less  than  85  per  cent,  nor  more  than  90  per  cent,  abso- 
lute lactic  acid.  It  occurs  as  a  colorless,  or  slightly  yellow,  syrupy 
liquid,  nearly  odorless,  having  an  acid  taste,  and  absorbing  moisture 
on  exposure  to  air.  Besides  being  miscible  with  water,  it  will  mix 
with  alcohol  and  ether  in  all  proportions.  The  average  dose  is 
30  min.  (2.0  mils). 

Physiologic  Action  and  Therapeutics. — ^Lactic  acid  acts  as  a 
mild  caustic  on  mucous  surfaces.  It  is  also  a  stimulant  and  re- 
frigerant. Younger  advocates  the  use  of  the  official  acid  as  a  stimu- 
lating agent  in  pyorrhea  alveolaris.  After  the  roots  are  scaled,  the 
acid  is  warmed  and  injected  into  the  pockets.  Stevens  recom- 
mends a  20  to  50  per  cent,  solution  to  be  applied  to  tuberculous  and 
lupous  ulcerations  oj  mucous  membranes. 

ARSENI  TRIOXIDUM— U.S.P. 

(Arsenic  Trioxid;  Airsenous  Acid;  White  Arsenic;  AS2O3.) 
Arsenic  trioxid  occurs  either  as  an  opaque,  white  powder,  or 
in  irregular,  heavy  masses  of  two  varieties:  one,  amorphous,  trans- 
parent, and  colorless,  like  glass;  the  other,  crystalline,  opaque,  and 
white,  resembling  porcelain.  Contact  with  moist  air  gradually 
changes  the  glassy  into  the  white,  opaque  variety;  and  frequently 
the  same  piece  has  an  opaque,  white  outer  crust  enclosing  the  glassy 
variety.  Both  are  odorless  and  tasteless.  The  drug  is  soluble  in 
water,  the  amorphous  or  glassy  variety  being  somewhat  more 
soluble  than  the  crystalHne  variety.  It  is  sparingly  soluble  in 
alcohol  and  ether,  but  freely  soluble  in  glycerin,  hydrochloric  acid 
and  alkahne  solutions.  In  the  presence  of  water  it  reacts  and  forms 
arsenous  acid  (HaAsOs).  The  average  dose  is  y^o  gr.  (0.002  Gm.). 
Physiologic  Action. — Internally  administered  in  the  proper  form 
and  dose  arsenic  acts  as  an  alterative  and  tonic,  improving  the 
appetite  and  increasing  the  secretions.  It  modifies  the  blood,  and 
in  this  manner  removes  morbid  conditions.  For  this  reason  it  is 
frequently  used  in  the  treatment  of  syphilis,  phthisis,  and  certain 
nervous  diseases.     Salvarsan  and  neosalvarsan,  newer  remedies  for 


lOO  ESCHAROTICS    OR   CAUSTICS 

syphilis,  and  which  will  be  discussed  later,  are  compounds  of  arsenic. 
The  drug  has  been  used  by  some  people  as  a  beautifier  of  the  com- 
plexion to  whiten  the  skin.  Care  must  be  exercised  in  gi\ang  arsenic 
internally  OT\'ing  to  its  cumulative  effect  which  may  develop  poisonous 
symptoms. 

It  is  the  local  action  in  which  dentists  are  most  interested. 
AppHed  to  denuded  surfaces,  such  as  an  exposed  pulp,  unless  its 
action  is  controlled,  arsenic  trioxid  is  a  powerful  and  painful 
escharotic.  It  is  readily  absorbed  by  the  tissue,  and  exerts  a  specific 
poisonous  action  upon  the  cells.  It  is  a  peculiar  escharotic,  and 
stands  in  a  class  by  itself.  Long^  states  that  "the  dry  powder  may 
be  placed  on  the  tongue  and  allowed  to  remain  for  one  minute 
■R-ithout  causing  the  slightest  irritation  and,  if  then  thoroughly- 
removed,  without  producing  any  efl'ect  upon  the  tissues.  On  the 
contrary,  if  it  is  allowed  to  remain  until  it  becomes  dissolved  and 
penetrates  the  tissues,  extensive  sloughing  will  result.  It  acts  only 
after  being  absorbed  by  the  tissue  elements,  altering  or  destroying 
their  lital  processes  in  an  obscure  manner.  Because  of  this  action 
it  is  difficult,  if  not  impossible,  to  limit  or  antagonize  its  influence 
upon  the  tissue  which  it  has  penetrated;  and  its  penetration  is  not 
limited  by  any  action  of  its  own,  as  it  does  not  coagulate  albumin. 
The  fact  of  its  being  tasteless  and  nonirritating  at  first  renders  its 
use  about  the  mouth  the  more  dangerous,  for  by  careless  handling 
it  may  become  lodged  about  the  teeth  or  beneath  the  edge  of  the 
gum,  and  its  presence  be  not  appreciated  for  hours,  until  devitalization 
of  the  tissue  has  begun." 

Under  certain  conditions,  which  are  not  well  understood,  the 
pulp  tissue,  though  exposed,  will  absolutely  resist  the  action  of 
arsenic  trioxid.  When  this  occurs  the  tissue  will  generally  be  found 
to  be  equally  resistant  to  other  drugs.  It  is  claimed  that  many  of 
the  peasants  of  Austria  have  acquired  a  toleration  for  the  drug,  and 
can  take  large  doses  wdthout  any  untoward  effects. 

Poisoning  and  Tretament. — Arsenical  poisoning  may  well  be 
considered  in  two  forms — local  and  systemic.  Local  arsenical  poison- 
ing occurs  most  frequently  by  the  escape  of  arsenical  preparations 
from  the  cavity  during  the  de\dtalization  of  pulp  tissue.  There  is 
seldom  any  pain  connected  with  the  devitalization  of  the  gum  tissue, 
and  herein  lies  the  great  danger  of  extensive  necrosis  of  the  soft  and 
frequently  the  bony  structures.  The  prominent  S5niiptom  is  a  white 
gum,  absolutely  lifeless;  there  may  be  pain,  most  frequently  this 
symptom  is  absent;  the  tooth  becomes  sore  to  percussion.     In  the 

^  Dental  Materia  Medica,  Therapeutics  and  Prescription  Writing. 


ARSENI   TRIOXrOUM  lOI 

more  severe  cases  the  destruction  of  soft  tissue,  if  unnoticed,  goes 
on  until  the  alveolar  process  between  the  affected  teeth  becomes 
involved  and  is  destroyed.  Sometimes  the  affected  tooth  is  lost, 
together  with  one  or  two  teeth  on  either  side. 

In  the  treatment  of  local  arsenical  poisoning  where  the  drug  has 
remained  only  long  enough  to  cause  devitalization  of  the  gum  tissue, 
all  that  is  necessary  is  to  first  wash  the  part  with  an  antiseptic  solution 
and  then  mechanically  pick  off  the  dead  or  sloughed  tissue  with  ster- 
ile pliers  until  hemorrhage  ensues,  if  this  is  possible;  after  which 
stimulating  disinfectants  should  be  employed.  Here  is  a  good  place 
to  use  the  official  solution  of  hydrogen  dioxid.  The  cavity  is  open 
and  there  is  no  danger  of  spreading  a  possible  infection.  After  re- 
moving the  dead  tissue  and  disinfecting,  the  author  suggests  drying 
the  part  and  covering  it  with  the  oleaginous  euroform  paste.  The 
patient  should  be  instructed  to  keep  the  mouth  clean  by  the  use  of  an 
antiseptic  wash,  and  the  local  treatment  repeated  every  day  until 
granulations  begin  to  form ;  usually  one  or  two  treatments  will  suffice. 

In  those  severe  cases  where  the  agent  has  penetrated  to  and  devi- 
talized the  alveolar  process,  as  well  as  the  overlying  soft  tissue,  the 
first  treatment  is  surgical.  After  washing  with  an  antiseptic  solution, 
the  affected  part  should  be  thoroughly  curetted  with  a  bone  curet 
or  a  suitable  bur  in  the  engine.  It  may  be  necessary  in  extensive 
cases  to  extract  the  affected  tooth,  after  which  the  treatment  is 
practically  the  same  as  has  been  outlined  above,  except  where  there 
has  been  much  removal  of  tissue  in  operating  it  is  best  to  pack  the 
part  at  first  with  plain  gauze  thoroughly  saturated  with  the  euro- 
form  paste.  The  case  should  be  watched  closely,  and  the  stimulat- 
ing treatment  kept  up  until  the  part  has  healed.  The  tissue  in  the 
interproximal  space  will  never  be  fully  reproduced,  and  will  always 
be  the  source  of  more  or  less  annoyance. 

Acute  systemic  arsenical  poisoning  is  manifested  by  severe  ab- 
dominal pains,  vomiting  and  purging  of  "rice-water,"  persistent 
thirst,  muscular  cramps,  .cyanosis,  and  collapse.  Death  usually 
occurs  in  from  one  to  three  days,  and  is  often  preceded  by  delirium, 
convulsions,  and  coma.  If  recovery  follows,  the  acute  symptoms 
may  be  gradually  replaced  by  those  of  chronic  arsenical  poisoning. 
This  condition  may  also  follow  the  prolonged  use  of  the  drug  as  a 
medicine,  may  result  from  the  use  of  foods  or  Hquors  contaminated 
with  arsenic  (beer,  etc.),  may  occur  from  constant  inhalation  of  dust 
arising  from  wall-paper  or  other  fabrics  colored  with  arsenical  pig- 
ments, or  may  be  acquired  by  workmen  in  arsenic  mines,  or  in  fac- 
tories in  which  fumes  of  the  metal  are  formed.     This  form  of  poison- 


I02  ESCHAROTICS    OR   CAUSTICS 

ing  may  be  manifested  by  gastroenteritis,  conjunctivitis,  and  catarrh 
of  the  upper  air-passages,  anemia,  peripheral  neuritis,  and  various 
cutaneous  lesions. 

In  the  treatment  of  acute  systemic  arsenical  poisoning,  emetics 
should  be  promptly  given  or  the  stomach  emptied  by  means  of  the 
stomach-pump.  The  best  chemic  antidote  is  freshly  prepared  ferric 
hydroxid  or  ferric  hydroxid  with  magnesia,  administered  while 
moist  in  doses  of  a  tablespoonful  or  more  every  ten  or  fifteen  minutes. 
These  compounds  themselves  are  harmless  and  act  by  forming  insol- 
uble arsenites.  Dialysed  iron  liberates  in  the  stomach  a  certain 
amount  of  free  ferric  hydroxid  and  may  also  be  given.  This  agent 
has  also  been  recommended  in  local  arsenical  poisoning,  but  its  use 
here  is  of  no  benefit,  and  is  wrong  (see  p.  329).  Demulcents  and 
opiates  are  usually  indicated. 

Therapeutics. — Arsenic  trioxid  is  used  only  in  dental  practice  for 
the  purpose  of  devitalizing  the  pulp  tissue.  The  agent  was  introduced 
to  the  dental  profession  by  Spooner,  of  Montreal,  in  about  1836. 
He  first  advocated  its  use  for  the  treatment  of  sensitive  dentin,  for 
he  discovered  that  by  sealing  the  drug  in  a  cavity  for  a  few  days,  the 
most  sensitive  dentin  yielded  to  its  influence.  The  fact,  however, 
that  nearly  all  teeth  thus  treated  subsequently  gave  trouble  because 
of  the  death  of  the  pulp  and  the  usual  sequelae,  led  the  profession  to 
abandon  this  agent  for  the  purpose  for  which  it  was  introduced ;  but 
it  has  ever  since  been  used  as  a  means  of  destroying  the  vitality  of 
the  pulp.  In  fact,  until  the  last  few  years,  it  was  the  only  agent 
employed  with  any  satisfaction.  The  detail  method  of  using  arsenic 
trioxid  as  a  devitalizing  agent  will  be  discussed  later.  It  is  well  to 
remember  here,  however,  that  when  the  drug  is  applied  to  the  pulp 
of  a  fully  developed  tooth,  its  action  and  effect  are  confined  to  the 
pulp  tissue  only,  as  the  organ  dies  by  strangulation  at  its  apex  due 
to  the  inflammatory  reaction  from  the  drug  when  thus  used.  Here 
thrombosis  and  death  of  the  pulp  take  place  and  absorption  of  the 
drug  by  continuity  is  not  hkely  to  occur.  This  is  not  true  in  teeth 
the  roots  of  which  are  not  fully  developed,  as  in  young  patients; 
therefore,  arsenic  trioxid  should  be  used  very  cautiously  in  such 
cases,  if  at  all.  This  does  not  mean  that  the  drug  may  be  used  indis- 
criminately in  any  case.  There  is  no  excuse  for  careless  technic  in 
the  local  use  of  the  agent. 

CHROMn  TRIOXIDUM— U.S.P. 

(Chromium  Trioxid;  Chromic  Acid;  CrOs.) 

Chromium  trioxid,  called  also  chromic  acid,  occurs  in  small, 
crimson  crystals  or  rhombic  prisms  of  metallic  luster.     The  drug  is 


OSMII   TETROXIDUM  IO3 

without  odor,  very  deliquescent,  and  thus  freely  soluble  in  water. 
It  should  be  "kept  in  glass-stoppered  bottles,  and  great  caution  should 
be  observed  to  avoid  an  explosion  when  brought  in  contact  with 
organic  substances,  such  as  cork,  tannic  acid,  sugar,  alcohol,  glycerin, 
ether,  and  collodion.  It  is  very  destructive  to  animal  and  vegetable 
tissues. 

Physiologic  Action  and  Therapeutics. — Chromic  acid  is  an  active 
escharotic,  due  to  its  powerful  oxidizing  influence.  Internally  ad- 
ministered, it  causes  intense  pain  in  the  abdomen,  vomiting  and 
purging;  often  there  is  blood  in  the  vomit  and  stools,  ultimately  col- 
lapse, which  frequently  ends  in  death.  Alkahes  neutralize  the  com- 
pound, but  the  salts  thus  formed  are  poisonous  and  the  stomach 
should  be  emptied  after  the  administration  of  the  antidote.  Chro- 
mium trioxid  has  been  employed  for  the  purpose  of  devitalizing  the 
pulp  tissue  in  children's  teeth.  Though  the  agent  may  be  considered 
safer  than  arsenic  trioxid,  because  it  is  less  penetrating,  its  action  is 
uncertain  and  unreHable.  Stevens  recommends  a  solution  of  from 
20-30  gr.  (1.3-2.0  Gm.)  to  the  ounce  (30.0  mils)  as  a  stimulating  ap- 
plication in  mucous  patches.  The  fused  crystals  on  a  suitable  probe 
may  be  used  with  excellent  results  in  the  removal  of  hypertrophied  gum 
or  pulp  tissue,  and  in  closing  small  salivary  fistulcB. 

Incompatibles. — With  organic  substances,  such  as  cork,  tannic 
acid,  alcohol,  glycerin,  etc.,  chromic  trioxid  easily  explodes. 

Potassium  Dichromate  (K2Cr207). — This  salt,  sometimes  called 
potassium  bichromate,  may  be  employed  in  weak  solutions  (5  per 
cent.)  in  indolent  ulcers,  mucous  patches  and  sloughing  wounds. 

OSMH  TETROXIDUM  (Nonofficial) 
(Osmium  Tetroxid;  Osmic  Acid;  OsOi.) 

Osmium  tetroxid,  called  also  osmic  acid,  occurs  in  yeUow,  crys- 
talline needles,  possessing  a  pungent  odor  and  burning  taste.  It  is 
slowly  soluble  in  water  (i  :  50) ;  also  soluble  in  alcohol  and  ether, 
but  the  solutions  decompose. 

Physiologic  Action  and  Therapeutics. — This  is  a  very  irritant 
and  caustic  agent.  When  injected  into  the  tissues,  even  in  weak 
solutions,  the  blood  and  tissues  turn  black,  but  healing  of  the  wound 
generally  proceeds  without  interruption.  Intraneural  injections 
are  used  to  produce  degeneration  of  nerves  for  the  relief  of  persistent 
neuralgias.  Murphy,  Bennett,  and  others  claim  excellent  results. 
The  affected  nerve  is  exposed  by  a  small  incision,  and  a  1.5  per  cent, 
solution,  freshly  prepared,  is  injected  into  its  substance  at  different 


I04  ESCHAROTICS    OR    CAUSTICS 

points,  to  the  amount  of  from  5-10  min.  (0.3-0.6  mil).  If  successful, 
the  effects  may  persist  for  several  months,  when  it  may  become  neces- 
sary to  repeat  the  injection  as  the  cure  is  rarely,  if  ever,  permanent. 
Murphy  especially  mentions  the  inherent  tendency  of  nerve  tissue 
to  regenerate. 

POTASSn  ET  SODH  (Nonofficial) 

(Kalium  and  Natrium;  Potassium  and  Sodium;  K  and  Na.) 

Potassiixm  and  sodium  are  known  in  chemistry  as  alkali-metals; 
they  vigorously  decompose  water  at  ordinary  temperatures,  forming 
the  hydroxid  (hydrate)  of  the  metal,  with  Hberation  of  hydrogen. 
The  metals  occur  in  soft  cyHnders,  having  a  silver- white  color;  and 
on  account  of  their  tendency  to  combine  with  oxygen  they  must  be 
kept  under  a  hydrocarbon  liquid,  such  as  coal-oil,  benzene,  etc. 

Action  and  Therapeutics. — Because  of  their  violent  action  on 
soft  tissue  they  are  not  used  as  such  in  medicine.  Schreier,  of 
Vienna,  introduced  a  mixture  of  these  metals  as  a  remedy  for  treat- 
ing gangrenous  root-canals.  When  the  mixture  is  placed  in  a  canal 
containing  dead  pulp  tissue  a  violent  reaction  takes  place,  water  is 
decomposed,  with  the  evolution  of  considerable  heat,  and  the  hy- 
droxids  of  the  metals  are  formed.  The  potassium  and  sodium 
hydroxids  unite  with  the  fatty  products  present  to  form  soluble 
soap,  which  may  be  removed  by  washing.  Thus  it  will  be  seen  that 
the  contents  of  the  canal  are  chemically  destroyed  and  physically 
removed,  leaving  the  canal  white  and  clean.  Rhein  recommends 
a  further  sterilization  of  the  canal  with  a  i  :  500  solution  of  mercury 
bichlorid  in  a  3  per  cent,  solution  of  hydrogen  dioxid.  The  use  of 
metallic  potassium  and  sodium  will  be  discussed  in  detail  in  that 
part  of  this  book  devoted  to  Practical  Therapeutics. 

POTASSn  HYDROXmUM— U.S.P. 

(Potassium  Hydroxid;  Caustic  Potash;  KOH.) 

Potassiiun  hydroxid,  more  commonly  called  caustic  potash, 
occurs  in  hard,  white,  translucent  pencils  or  fused  masses,  odorless, 
and  having  an  acrid  and  caustic  taste.  It  is  freely  soluble  in  water 
and  in  alcohol.     The  ofi&cial  preparation  is: 

Liquor  Potassii  Hydroxidi,  U.S. P.  (5  per  cent.). 

SODn  HYDROXIDUM— U.S.P. 

(Sodium  Hydroxid;  Caustic  Soda;  NaOH.) 

Sodium  hydroxid,  or  caustic  soda,  occurs  in  hard,  white,  trans- 
lucent pencils  or  fused  masses,  odorless,  and  having  an  acrid  and 


soDii  HYDROxromi  105 

caustic  taste.     It  is  freely  soluble  in  water  and  in   alcohol.     The 
official  preparation  is : 

Liquor  Sodii  Hydroxidi,  U.S. P.  (5  per  cent.). 

Physiologic  Action  and  Therapeutics. — The  action  of  caustic 
potash  and  caustic  soda  is  similar.  They  may  be  classed  among 
the  strongest  and  most  penetrating  escharotics  known.  They 
should  he  handled  about  the  mouth  and  other  soft  tissues  with  the 
greatest  caution.  Their  action  is  both  rapid  and  painful.  When 
applied  to  soft  tissue  they  produce  a  slough  which  separates  in  a 
few  days  leaving  a  granulating  ulcer.  The  escharotic  effect  is 
caused  by  the  abstraction  of  water  from  the  tissues;  this  softens  the 
latter,  and  the  hydroxyl  radical  forms  with  the  proteids  a  soluble 
alkaline  albuminate.  When  either  are  taken  internally  in  large 
doses  they  produce  all  the  symptoms  of  corrosive  poisoning — burn- 
ing in  the  throat  and  esophagus,  intense  pain  in  the  abdomen,  vom- 
iting and  purging  of  mucus  and  bloody  matter,  dysphagia,  and 
ultimate  collapse.  Small  doses  freely  diluted  have  the  same  action 
as  the  alkaline  carbonates — that  of  an  antacid. 

Caustic  potash  and  caustic  soda  are  sometimes  employed  in 
dental  practice  to  destroy  exuberant  granulations.  They  are  also 
used  in  about  10  per  cent,  solutions  to  cauterize  and  destroy  a 
remnant  of  a  pulp  and  to  disorganize  and  aid  in  the  removal  of  all 
organic  material  from  the  canals  of  pulpless  teeth.  This  is  recog- 
nized to-day  as  absolutely  essential  in  the  treatment  of  these  teeth. 
Whenever  these  alkahes  are  employed  in  the  canals  of  teeth,  care 
must  be  taken  not  to  force  them  through  the  root-end,  and  their 
caustic  action  should  be  neutralized  with  weak  acids. 

Treatment  of  Poisoning. — The  treatment  of  poisoning  with 
the  caustic  alkalies  to  be  effective  must  be  prompt.  Dilute  acetic 
acid  or  vinegar  will  neutralize  the  alkali  and  should  be  given  at  once. 
Demulcent  drinks  are  indicated  to  soothe  the  corroded  parts,  and 
opium  to  control  the  pain. 

Hydrofluoric  Acid  (HF). — This  is  a  colorless  gas,  freely  soluble 
in  water.  It  may  be  obtained  commercially  in  solution,  and  because 
of  its  power  to  etch  glass,  it  must  be  kept  in  rubber  or  gutta-percha 
bottles.  On  account  of  its  extremely  irritating  and  penetra  ng 
property,  it  is  not  employed  as  a  therapeutic  agent,  but  is  u  ed 
extensively  in  dentistry  for  etching  porcelain  inlays.  It  must  be 
handled  with  the  greatest  care,  for  if  it  is  accidentally  applied  to  the 
soft  tissue  and  not  instantly  neutralized  it  will  penetrate  deeply 


I06  IRRITANTS   AND    COUNTERIRRITANTS 

and  produce  an  ugly  ulcer.  Many  cases  of  sevef^  local  poisoning 
by  the  agent  have  been  reported,  and  it  is  largely  for  this  reason 
that  it  has  been  included  in  this  work  on  therapeutics. 

The  treatment  of  local  poisoning  consists  in  neutraHzing  the 
drug  chemically  by  the  use  of  alkalies.  A  weak  solution  (5  per 
cent.)  of  ammonia  water  serves  the  purpose  nicely,  and  the  sooner 
the  application  is  made  after  the  discovery  of  the  burn,  the  less 
destruction  of  tissue  there  will  be.  To  apply  the  antidote,  the  part 
can  be  wrapped  in  plain  sterile  gauze  and  this  saturated  with  the 
remedy.  The  ammonia  will  irritate  the  part  and  probably  cause 
pain,  but  the  acid  must  be  neutralized,  even  at  the  expense  of  caus- 
ing pain.  After  we  are  reasonably  certain  that  the  acid  is  neutral- 
ized, the  burn  should  be  antiseptically  treated  in  the  usual  way. 
The  euroform  paste  is  an  excellent  remedy  to  employ. 

Ionization. — This  is  the  process  of  dissociating  the  ions  or  radicals 
of  a  salt  or  compound  by  setting  them  free  by  means  of  the  electric 
current  (electrolysis).  When  the  process  is  used  in  the  treatment 
of  disease,  it  is  called  ionic  medication.  Ionization  with  solutions 
of  zinc  chlorid  and  iodin  is  frequently  used  in  the  -treatment  of 
dental  granulomas  and  infections  about  the  root-ends  of  pulpless 
teeth.  Whether  the  benefit  comes  from  the  supposed  fact  that  the 
tissues  thus  treated  are  sterilized  by  virtue  of  the  ions  being  set  free, 
or  from  the  cauterization  by  the  current  used,  is  a  debatable  ques- 
tion.    Price  is  of  the  latter  opinion. 

Actual  Cautery. — The  cauterization  of  tissue  by  means  of  heat 
should  be  considered  briefly  under  the  heading  of  Escharotics. 
This  is  accomplished  by  means  of  the  hot  iron  or  platinum  wire, 
or  the  galvano-cautery,  and  affords  a  prompt  and  powerful  means  of 
destroying  tissue.  The  process  is  not  as  painful  as  one  would  natur- 
ally suppose,  and  may  be  used  for  the  purpose  of  destroying  hyper- 
trophied  gum  tissue  and  other  growths.  The  dental  switch  boards 
have  an  attachment  by  which  this  means  of  cauterization .  may  be 
easily  and  practically  applied. 


IRRITANTS  AND  COUNTERIRRITANTS 

Irritants  have  been  elsewhere  defined  as  agents  which,  when 
appHed  to  the  skin  or  mucous  membrane  of  the  mouth,  produce 
active  hyperemia  or  inflammation.  When  irritants  are  applied  to 
a  normal  part  for  the  purpose  of  influencing  favorably  a  diseased 
part,  usually  deep-seated,  they  are  called  counterirritants,  and  the 


IRRITANTS  AXD  COUNTERIREITANTS  I07 

process  counterirritation.  It  is  for  this  latter  purpose  that  irritants 
are  largely  employed  in  dentistry.  The  extent  to  which  counter- 
irritation  may  be  carried  depends  upon  how  severely  diseased  is  that 
part  which  the  irritation  of  the  normal  part  is  intended  to  influence. 
The  agents  used  are  subdivided  into  different  classes  according 
to  the  degree  of  irritation  folloT\-ing  their  appUcation.  Those  which 
simply  produce  active  h\'peremia  (redness)  of  the  surface  are  called 
rubefacients;  those  which  act  more  severely  and  cause  the  formation 
of  a  bhster  are  known  as  vesicants  or  epispastics.  In  many  instances 
the  same  agent  may  produce  a  rubefacient  or  a  vesicant  effect, 
depending  upon  the  strength  of  the  drug  and  the  duration  of  its 
apphcation. 

Counterirritation  may  be  carried  to  a  greater  degree  of  intensity 
■when  a  true  escharotic  effect  (destruction  of  tissue)  is  produced. 
This,  however,  is  seldom  necessary  in  dental  practice.  In  fact,  as 
a  rule,  it  should  be  guarded  against,  for  the  formation  of  an  ulcer 
in  the  mouth  is  Kable  to  so  cripple  the  cells  that  a  mixed  infection 
may  readily  follow. 

Care  should  be  exercised  in  the  application  of  counterirritants 
when  the  inflammation  is  superficial.  To  apply  an  irritant  directly 
to  an  inflamed  part  would  only  tend  to  aggravate  the  condition. 
Here  the  site  of  apphcation  should  be  a  short  distance  from  the 
diseased  part.  In  all  deep-seated  inflammations,  or  in  cases  of 
neuralgia,  it  is  best  to  make  the  apphcation  directly  over  the 
affected  part. 

Long^  states  that  "the  remedial  effect  of  a  counterirritant  is 
probably  brought  about  by  a  threefold  action.  They  influence, 
first,  the  circulation  by  causing  a  hA^peremia  at  the  point  of  irrita- 
tion, the  tendency  of  the  blood  supply  will  be  in  that  direction  and 
away  from  the  original  disease;  second,  they  turn  the  attention  of 
the  system  toward  the  new  point  of  irritation  and  away  from  the 
disease,  partly  a  mental  effect;  and,  third,  they  influence  the  inner- 
vation of  the  diseased  part  by  the  reflex  influence  of  the  irritation. 
In  the  sum  of  their  effects  they  stimulate  the  movement  of  fluids 
within  the  tissues;  hence  they  are  regarded  as  honphatic  stimulants, 
and  are  often  employed  to  stimulate  the  absorption  of  a  serous  or 
inflammatory  exudate." 

Counterirritation  may  be  said  to  be  truly  indicated  in 
dental  practice  in  the  treatment  of  pericementitis  and  trigeminal 
neuralgia. 

^  Dental  Materia  Medica,  Therapeutics  and  Prescription  Writing. 


Io8  IRRITANTS   AND    COUNTERIRRITANTS 

The  most  important  irritants  used  in  dentistry  for  counter- 
irritation  are: 

Heat.  Cantharides. 

lodin.*  Chloroform. 

Capsicum.  Aconite. 

Mustard.  Camphor. 

•  Oil  of  Turpentine.  ,  Volatile  Oils.* 

Menthol.* 

Heat. — This  physical  agent  occupies  a  prominent  place  in 
dentistry  as  a  counterirritant,  because  of  the  convenience  of  the 
variety  of  forms  and  the  different  degrees  in  which  it  can  be  utilized. 
Moderate  heat  applied  over  a  deep-seated  inflammation  will  at  once 
produce  active  h3q3eremia.  The  heat  may  be  gradually  carried  to 
a  higher  degree  with  comfort  to  the  patient  until  the  serum  escapes 
from  the  engorged  blood-vessels,  thus  promoting  resolution.  Hot 
water,  the  hot-water  bag,  hot  foot-bath,  and  dry  and  moist  poultices, 
are  all  employed  in  various  manners  in  the  treatment  of  pericemen- 
titis, acute  alveolar  abscess,  neuralgias,  and  for  the  absorption  of 
serous  or  inflammatory  exudates. 

.     CAPSICUM— U.S.P. 
(Cayenne  Pepper.) 

Capsicum  is  the  dried  ripe  fruit  of  Capsicum  frutescens,  a  plant 
growing  in  tropical  America,  in  Asia,  in  Africa,  and  cultivated  in 
gardens.  The  active  principle  is  capsicin,  which  appears  in  the 
form  of  colorless  crystals  and  has  an  exceedingly  pungent  odor;  other 
constituents  are  a  volatile  alkaloid,  fixed  and  volatile  oil,  and  fatty 
acids.  The  average  dose  is  i  gr.  (0.06  gm.).  All  of  the  official 
preparations  may  be  used  in  dentistry.     They  are: 

Tinctura  Capsici,  U.S. P.     Dose,  8  min.  (0.5  mil). 
Oleoresina  Capsici,  U.S. P.     Dose,  }i  gr.  (0.03  Gm.). 
Emplastrum  Capsici,  U.S. P.  (externally). 

Physiologic  Action. — Applied  to  the  skin  or  mucous  membrane, 
capsicum  produces  a  burning  sensation  and  results  in  a  rubefacient 
or  vesicant  effect,  depending  upon  the  concentration  of  the  drug. 
Taken  internally,  in  medicinal  doses,  it  creates  a  sense  of  warmth 
in  the  stomach,  stimulates  the  circulation,  and  aids  the  digestive 
process.     In  large  doses  it  acts  as  an  irritant  poison. 

Therapeutics. — Capsicum  is  used  chiefly  as  a  rubefacient, 
stomachic,  and  carminative.  In  dentistry  advantage  is  taken  of 
its  irritant  properties,  and  it  is  largely  employed  as  a  counterirri- 


SINAPIS  ALBA — SINAPIS  NIGRA  IO9 

tant  in  pericementitis.  The  oleoresin  is  the  most  irritating  prepara- 
tion. The  official  plaster  may  be  prepared  by  spreading  the  oleo- 
resin upon  resin  plaster;  this  may  be  cut  in  convenient  form  and 
applied  to  the  dried  gum  over  the  affected  tooth,  resulting  in  a  small 
blister,  but  having  a  beneficial  effect  upon  the  deep-seated  inflam- 
mation. When  a  rubefacient  effect  only  is  desired,  the  powdered 
drug  may  be  confined  in  small  concave  rubber  disks  and  pressed  on 
the  gum,  suction  holding  the  remedy  in  place. 

SINAPIS  ALBA— U.S.P. 

(White  Mustard.) 

SINAPIS  NIGRA— U.S.P. 

(Black  Mustard.) 

White  mustard  is  the  seed  of  Sinapis  alba.    Black  mustard  is 

the  seed  of  Brassica  nigra.  Both  of  these  herbs  are  cultivated  exten- 
sively in  Europe  aiid  America.  The  powdered  mustard  of  com- 
merce is  a  ground  mixture  of  white  and  black  seed,  often  more  or 
less  adulterated.  Mustard  in  the  dry  state  is  not  irritating,  but  in 
the  presence  of  water  it  is  extremely  irritating,  and  for  this  reason : 
White  mustard  contains  a  ferment,  myrosin,  and  a  glucosid,  sinalhin. 
In  the  presence  of  water  the  myrosin  acts  upon  the  sinalbin  and 
separates  from  it  an  irritant  volatile  oil. 

Black  mustard  contains  the  same  ferment,  myrosin,  and  a 
glucosid,  sinigrin,  which  by  the  action  upon  it  of  the  ferment  in  the 
presence  of  water  also  converts  it  into  an  intensely  irritant  volatile 
oil.  This  oil  of  mustard  is  official,  and  to  it  is  due  both  the  pungent' 
taste  and  odor  of  the  moistened  powder.  Average  emetic  dose, 
2}4  dr.  (10. o  Gm.).     The  following  preparation  is  official: 

Oleum  Sinapis  Volatile,  U.S.P.  (Volatile  Oil  of  Mustard). 
Dose,  14.  iiiin.  (0.008  mil). 

Physiologic  Action. — Mustard  made  into  a  paste  with  water 
and  applied  to  the  skin,  or  the  powder  applied  to  the  moist  mucous 
membrane,  causes  redness,  heat,  and  a  burning  pain.  Any  degree 
of  irritation,  from  a  slight  rubefacient  effect  to  severe  vesication, 
may  be  produced.  It  should  be  remembered  that  the  presence  of 
moisture  is  necessary  for  the  irritant  action  of  mustard,  the  dry 
powder  is  not  irritating.  Hot  water  should  not  be  used,  as  the  high 
heat  tends  to  destroy  the  ferment  necessary  to  evolve  the  irritating 
oil  from  the  glucosid. 

Taken  internally  in  small  doses,  mustard  acts  as  a  carminative. 


no  IRRITANTS   AND    COUNTERIRRITANTS 

In  large  doses  it  acts  as  an  emetic,  producing  prompt  emesis  without 
depression,  owing  to  the  reflex  stimulation  of  the  cardiac  and 
respiratory  centers. 

Therapeutics. — Mustard  is  useful  in  dentistry  as  a  rubefacient. 
The  paper,  which  was  formerly  ofl&cial,  cut  in  proper  form,  may  be 
applied  to  the  moist  gum  in  nonseptic  pericementitis.  Concave 
rubber  cups  may  also  be  used  to  hold  the  powder,  and  applied  by 
suction.  Powdered  mustard  may  be  mixed  with  warm  water  to  bring 
about  the  reaction  necessary  to  produce  the  irritant  volatile  oil,  and 
this  added  to  the  hot  water  in  taking  a  hot  foot-bath  for  counter- 
irritant  purposes.  To  add  the  mustard  direct  to  the  hot  water 
would  defeat  the  object  for  which  the  drug  is  used,  as  the  heat  checks 
the  action  of  the  ferment. 

On  account  of  the  prompt  emetic  properties  of  mustard  the  drug 
may  be  employed  in  cases  of  narcotic  poisoning,  the  dose  being  a 
tablespoonful  stirred  up  in  warm  water,  and  repeated  in  fifteen 
minutes,  if  necessary. 

The  drug  is  sometimes  used  in  neuralgia  and  muscular  rheumatism. 
The  blisters  produced  by  mustard  heal  with  difficulty;  therefore, 
extensive  vesication  should  be  guarded  against. 

TEREBINTHINA  (Nonofficial) 
(Turpentine.) 

Turpentine  is  a  solid  oleoresin,  or  pitch,  obtained  from  Pinus 
palustris  and  other  species  of  Pinus,  growing  in  the  Southern  United 
States,  especially  in  North  Carolina.  The  oleoresin  exudes  from 
the  pine  tree  when  the  bark  is  cut,  and  when  subjected  to  distilla- 
tion it  yields  a  volatile  oil,  which  is  official,  and  a  solid  residue  called 
resin  or  rosin,  also  official. 

OLEUM  TEREBINTHINA— U.S.P. 

(Oil  of  Turpentine.) 

Oil  of  turpentine  is  a  thin,  colorless  liquid,  highly  inflammable, 
and  of  a  characteristic  odor  and  taste.  It  should  be  kept  in  well- 
stoppered  bottles,  protected  from  light.  The  rectified  oil  is  made  by 
distilling  the  ordinary  oil  with  lime-water.  This  is  the  preparation 
which  is  largely  used  in  dentistry  and  the  one  always  used  for  internal 
medication.  Average  dose  is  lo  min.  (0.6  mil)  in  emulsion.  The 
official  preparations  are: 

Oleum  Terebinthinae  Rectificatum,  U.S. P. 
Emulsum  Olei  Terebinthinae,  U.S. P.  (15  per  cent.). 
Liniment  Terebinthinae,  U.S. P.  ('35  per  cent,  with  Resin 
Cerate). 


EESINA  III 

Physiologic  Action. — When  applied  to  the  skin,  the  drug  dilates 
the  cutaneous  blood-vessels,  producing  a  sensation  of  heat  and  red- 
ness, and,  if  continued  long,  vesication  follo'ws.  The  drug  has  de- 
cided antiseptic  properties,  and  even  in  dilute  solutions  prevents 
fermentation  and  putrefaction.  Taken  internally  in  medicinal  doses, 
it  produces  warmth  in  the  stomach,  quickened  respiration,  and  in- 
creases the  rate  and  tension  of  the  pulse.  It  also  acts  as  a  circula- 
tory stimulant  and  diuretic. 

In  large  doses  it  produces  all  the  s}Triptoms  of  an  irritant  poison. 
Some  individuals  are  pecuHarly  susceptible  to  the  drug,  and  an 
erythematous  or  papular  eruption  may  result  from  either  its  internal 
or  external  use. 

Therapeutics.' — Externally,  oil  of  turpentine  may  be  used  as  a 
rubefacient  in  various  inflammatory  affections.  In  an  aciite  alveolar 
abscess  a  turpentine  stupe  may  be  employed  to  advantage.  The 
latter  is  made  by  soaking  a  large  piece  of  flannel  in  boihng  water, 
wringing  it  dry,  and  folding  it  several  times  until  it  is  about  6  in. 
square;  from  lo  to  30  min,  (0.6-2.0  mils)  of  the  oil  are  then  distrib- 
uted over  it,  and  it  is  quickly  apphed  to  the  cheek  of  the  affected 
side  and  covered  with  several  layers  of  fabric.  The  official  liniment 
makes  an  excellent  remedy  to  be  applied  in  cases  of  neuralgia  and 
muscular  rheufnatism. 

RESINA— U.S.P. 

(Rosin;  Colophony.) 

Rosin  is  the  residue  left  after  distilling  the  volatile  oil  from  the 
concrete  oleoresin  obtained  from  Pinus  palustris,  and  from  other 
species  of  Pinus.  It  generaUy  occurs  in  sharp,  angular,  transparent, 
amber-colored  fragments,  frequently  covered  T\dth  a  yellow  dust; 
brittle  at  the  ordinary  temperature;  odor  and  taste  slightly  terebin- 
thinate.  It  is  freely  soluble  in  alcohol,  ether,  chloroform,  benzene, 
fixed  or  volatile  oils.     There  is  one  official  preparation: 

Emplastrum__Resinae;  U.S. P.  (Rosin  Plaster). 

Therapeutics. — Rosin  is  recommended  by  Callahan  to  be  dis- 
solved in  chloroform,  making  a  thin  solution  to  be  used  in  filling  the 
canals  of  pulpless  teeth  with  gutta-percha.  Callahan's  "rosin  solu- 
tion" contains  rosin  12  gr.  (0.8  Gm.)  and  chloroform  3  fl.  dr.  (12.0 
mils). 


112  IRRITANTS    AND    COUNTERIRRITANTS 

TEREBENUM— U.S.P. 

(Terebene.) 

This  is  a  liquid  hydrocarbon  made  by  oxidizing  oil  of  turpentine 
with  strong  sulphuric  acid.     The  average  dose  is  4  min.  (0.25  mil). 

Terebene  has  proved  to  be  a  very  satisfactory  remedy  in  bronchitis 
with  free  expectoration.  It  has  also  been  used  in  phthisis,  and  may 
be  inhaled  from  a  spray  or  from  the  sponge  of  a  respirator.  Harlan 
recommended  its  use  for  gangrenous  root-canals;  but,  like  the  essen- 
tial oils,  its  use  here  is  unreliable. 

CANTHARIS— U.S.P. 

(Cantharides;  Spanish  Flies.) 

Cantharides,  commonly  called  Spanish  fly,  is  the  dried  and  pow- 
dered beetle  or  insect,  Cantharis  vesicatoria,  indigenous  to  Southern 
and  Central  Europe.  The  active  principle  is  cantharidin,  which  is 
also  found  in  a  number  of  beetles.  The  drug  is  used  only  externally 
in  dentistry.     The  official  preparations  are: 

Tinctura  Cantharidis,  U.S. P. 
Ceratum  Cantharidis,  U.S. P. 
CoUodium  Cantharidatum,  U.S. P.  (60  per  cent.). 

Physiologic  Action. — Cantharides  is  a  powerful  irritant,  though 
rather  slow  in  its  action.  When  applied  to  the  skin  or  mucous  mem- 
brane, the  drug  excites  a  tingling  and  burning  sensation,  producing 
redness  and,  later,  vesication.  Its  long-continued  application  often 
results  in  pustulation,  ulceration,  and  sloughing. 

Butler  states  that  the  drug  not  only  causes  vascular  dilatation 
of  the  part  to  which  it  is  applied,  but  reflexly  dilates  the  blood-vessels 
of  the  deep-seated  organs  underneath,  thus  acting  as  a  counter- 
irritant. 

The  active  principle,  cantharidin,  may  be  absorbed  through  the 
unbroken  skin,  and  is  quite  readily  absorbed  through  the  mucous 
membrane,  thus  its  constitutional  effects  may  result  from  the  exter- 
nal use  of  the  drug.  The  toxic  symptoms  are  great  pain  in  the 
throat,  stomach,  and  bowels,  excessive  thirst,  irritation  of  the  geni- 
tourinary tract  with  a  desire  to  urinate  constantly,  albuminous  and 
bloody  urine,  painful  erections  of  the  penis  in  males,  and  in  women 
abortion  may  follow  the  irritant  effect  of  the  drug  upon  the  pelvic 
viscera.     While  these  symptoms  are  not  liable  to  follow  the  use  of 


ACONITUM  113 

the  drug  in  dental  practice  where  a  limited  area  is  selected  as  the  site 
of  application  for  counterirritant  purposes,  it  is,  nevertheless,  well 
to  be  familiar  with  them. 

Treatment  of  Poisoning. — The  stomach  should  be  emptied, 
and  demulcents  given  freely  to  relieve  the  irritation.  Opium  may 
be  required  to  relieve  the  pain,  and  stimulants  administered,  if 
necessary.  Oils  and  fatty  substances  dissolve  the  cantharidin,  and 
thus  hasten  its  absorption;  they  should  therefore  be  avoided  as 
demulcents. 

Therapeutics. — Cantharides  may  be  used  as  a  counterirritant 
in  cases  of  severe  pericementitis,  and  as  it  dilates  the  arterioles  sub- 
jacently  the  effect  of  the  drug  will  ultimately  afford  relief.  Its 
action  is  slow  but  certain.  The  cerate  may  be  applied  as  a  plaster 
or  the  collodion  as  a  varnish.  To  insure  greater  activity  of  the  drug, 
the  site  of  application  should  be  oiled.  In  facial  neuralgia  canthar- 
ides is  valuable,  the  preparation  being  applied  behind  the  ear. 

ACONITUM— U.S.P. 

(Aconite;  Wolfsbane;  Monkshood.) 

Aconite  is  official  in  the  form  of  the  dried  tuberous  root  of  Aconi- 
tum  Napellus,  a  plant  growing  in  Europe,  Asia,  and  in  America, 
mostly  in  mountainous  regions.  The  root  closely  resembles  horse- 
radish; the  latter,  however,  has  a  pungent  odor  when  scraped,  while 
aconite  is  odorless.  The  root  at  first  has  a  sweetish  taste,  but  soon 
produces  a  sense  of  warmth  and  tinghng,  followed  by  numbness. 
The  active  principle  is  aconitin,  also  official  under  the  title  Aconitina, 
U.S.P.  This  is  an  alkaloid,  occurring  in  colorless  or  white  rhombic 
prisms  or  prismatic  powder,  is  without  odor,  permanent  in  the  air, 
and  when  brought  in  contact  with  the  mucous  membrane,  even  in 
dilute  solutions,  produces  a  characteristic  tingUng  and  more  or  less 
anesthesia.  The  average  dose  of  aconitin  is  3-^00  gr-  (0.00015  Gm.). 
The  official  preparations  of  aconite  are: 

Tinctura  Aconiti,  U.S.P.  (10  per  cent.).     Dose,  5  rain.  (0.3 

mil). 

Fluidextractum  Aconiti,  U.S.P.     Dose,  ^i  min.  (0.03  mil). 

Extractum  Aconiti,  U.S.P.     Dose,  %  gr.  (o.oi  Gm.). 

Linimentum  Aconiti  (nonofl&cial;  externally). 

Physiologic  Action. — Aconite  is  a  true  circulatory  depressant. 
It  may  also  be  considered  a  nervous  sedative.  AppHed  to  the  mucous 
membrane  or  to  the  skin  for  any  length  of  time,  it  first  irritates,  caus- 


114  IRRITANTS    AND    COUXTERIRRIT.IXTS 

ing  stimulation,  and  then  depresses  the  sensory  nerve-endings,  pro- 
ducing, respectively,  tingling,  numbness,  and  local  analgesia.  The 
drug  lowers  the  blood-pressure  by  directly  depressing  the  heart. 
In  the  febrile  state,  moderate  doses  of  aconite  cause  a  decided  fall  of 
temperature.  Butler  claims  this  is  due  to  various  causes:  (i)  The 
slowing  of  the  circulation,  diminishing  the  metabolism;  (2)  the 
peripheral  action  of  the  drug,  causing  dilatation  of  the  cutaneous 
blood-vessels;  (3)  the  depressant  action  upon  all  muscle-tissue. 

Toxicology. — Poisoning  by  aconite  is  first  manifested  by  a  pecu- 
liar tinghng  sensation  of  the  tongue  and  lips,  which  soon  extends  to  the 
fingers,  and  may  afi'ect  the  entire  surface  of  the  skin.  The  pulse  be- 
comes slow  and  weak;  later  it  may  become  rapid  and  irregular;  the 
respiration  is  slow  and  feeble.  There  is  an  extreme  muscular  weak- 
ness, especially  noticeable  in  the  lower  extremities. 

Treatment  of  Poisoning. — The  patient  should  be  kept  in  a 
recumbent  position,  the  feet  slightly  raised.  The  stomach  should 
be  thoroughly  emptied,  keeping  the  patient  in  this  position.  Ex- 
ternal apphcations  of  heat  should  be  made  to  raise  the  tempera- 
ture, and  diffusible  stimulants,  such  as  alcohol  and  aromatic  spirit 
of  ammonia,  should  be  given;  strychnin,  atropin,  and  digitalis  may 
be  h}'podermically  administered  for  their  eft'ect  upon  the  cardiac 
and  respiratory  centers;  and,  if  necessary,  artificial  respiration  should 
be  employed. 

Therapeutics. — Though  the  first  eff'ect  of  aconite,  locally  applied, 
is  that  of  an  irritant,  it  has  not  been  discussed  here  because  of  this 
property;  but  rather  for  the  reason  that  certain  preparations  of  the 
drug,  notabh'  the  tincture,  have  long  been  used  in  dental  practice 
as  a  constituent  of  counterirritant  remedies  for  the  treatment  of 
apical  pericementitis  and  facial  neuralgia.  Tincture  of  aconite  has 
been  extensively  used  to  dilute  the  tincture  of  iodin  for  dental  pur- 
poses. A  favorite  Hniment  of  the  author's  for  nonseptic  pericemen- 
titis is:  Menthol,  20  gr.  (1.3  Gm.) ;  chloroform,  i}i  A-  dr.  (6.0  mils) ; 
tincture  of  aconite,  6yi  A-  dr.  (26.0  mils).  The  therapeutics  of 
aconite  \d\\  be  discussed  more  fully  later. 

CAMPHORA— U.S.P. 

(Camphor;  CioHieO.) 

Camphor  is  a  stearoptene  obtained  from  Cinnamomum  Camphora, 
a  tree  indigenous  to  Eastern  and  Southeastern  Asia,  and  cultivated 
in  Italy  as  an  ornamental  tree.     The  drug  occurs  in  white,  trans- 


CAMPHOR  115 

lucent  masses,  of  a  tough  consistence  and  crystalline  structure, 
readily  pulverizable  in  the  presence  of  a  little  alcohol,  ether,  or 
chloroform.  It  is  sparingly  soluble  in  water,  but  freely  soluble  in 
alcohol,  ether,  chloroform,  fixed  and  volatile  oils.  When  camphor 
is  triturated  in  about  equal  proportions  with  menthol,  thymol, 
phenol,  or  chloral  hydrate,  a  syrupy  liquid  results.  The  average 
dose  is  2  gr.  (0.125  Gm.).     The  following  preparations  are  official: 

Aqua  Camphorse,  U.S. P. 

Linimentum  Belladonnae,  U.S. P.  (5  per  cent.). 

Linimentum  Camphorae,  U.S. P.  (20  per  cent,  in  Cottonseed 

Oil). 

Linimentum  .Chloroformi,  U.S. P.  (30  per  cent.  Chloroform 

in  Soap  Liniment.). 

Linimentum  Saponis,  U.S. P.  (4.5  per  cent.). 

Spiritus  Camphorae,  U.S. P.  (10  per  cent.). 

Tincturas  Opii  Camphorata,  U.S. P.  (Camphorated  Tincture 

of  Opium;  Paregoric;  0.4  per  cent.).     Dose,  2  fl.  dr.  (8.0  mUs). 

Physiologic  Action. — Upon  the  unbroken  skin,  camphor  acts  as 
an  anesthetic;  but  on  the  mucous  membrane  it  is  irritating,  and  in 
concentrated  form  may  produce  inflammation  and  even  sloughing. 
In  medicinal  doses  it  acts  as  a  carminative  and  antispasmodic.  In 
large  doses,  it  causes  confusion  of  thought,  headache,  gastric 
irritation,  a  rapid  feeble  pulse,  convulsions,  and  collapse. 

Therapeutics. — Camphor  is  used  as  a  rubefacient,  circulatory 
stimulant,  and  antispasmodic.  The  spirit  of  camphor  has  long  been 
a  household  remedy  for  headache,  syncope,  and  faintness.  It  is  ad- 
ministered by  inhalation;  camphorated  oil  (5  per  cent,  of  camphor  in 
oHve  oil)  is  a  useful  remedy  in  colds  and  croup.  The  Hniments 
containing  camphor,  as  well  as  the  spirit,  are  extensively  used  in 
sprains,  bruises,  muscular  rheumatism,  and  neuralgia.  Prinz  advo- 
cates a  combination  of  thymol  (2  parts),  phenol  crystals  (2  parts), 
and  camphor  (i  part),  called  thymocamphen,  as  an  anodyne  in  root- 
canal  treatment.  In  acute  coryza,  Stevens  recommends  adding  a 
teaspoonful  of  powdered  camphor  to  a  tumbler  of  hot  water,  and 
inhahng  the  fumes. 

EMOLLIENTS,   DEMULCENTS,  AND   PROTECTIVES 

Emollients  are  substances  of  a  fatty  nature  which  soften  and 
relax  the  tissue  to  which  they  are  appKed,  and  at  the  same  time 
shield  the  part  from  external  irritation. 


Il6  EMOLLIENTS,    DEMULCENTS,    AND   PROTECTIVES 

The  most  important  emollients  are : 

Glycerin.  Fats  and  Oils: 

Soap  Liniment.  Lard. 
Starch.                                               .         Olive  OU. 

Hot  Fomentations.  Almond  Oil. 

Poultices:  Linseed  OU. 

Linseed  Meal.  Cottonseed  Oil. 

Oatmeal.  Lanolin. 

Bran.  Petrolatum. 

Bread.  Parafi&n. 

Flour.  Cacao  Butter. 

Figs,  etc.  Wax. 

Demulcents  are  substances  largely  of  a  mucilaginous  character 
which  soothe  and  protect  the  tissues  to  which  they  are  applied. 
The  important  demulcents  are: 

Acacia.  MarshmaUow. 

Tragacanth.  White  of  Egg. 

Licorice  Root.  Sassafras  Pith, 

Flax  Seed.  Slippery  Elm. 

P^otectives  are  agents  used  to  mechanically  cover  and  protect 
injured  or  diseased  surfaces  from  extraneous  influences,  as  air,  water, 
bacteria,  etc.  Some  protectives,  besides  affording  mechanical  pro- 
tection to  the  part,  also  absorb  moisture  or  fluids  by  capillary  attrac- 
tion. The  so-called  dusting  powders  2ind  fixed  dressings  are  included 
in  this  group.     The  chief  protectives  are: 

Collodion.  Talc. 

Solution  of  Gutta-percha.  Kaolin. 

Court  Plaster.  Lycopodium. 

Charcoal.*  Zinc  Oxid.* 

Animal  Charcoal.*  Chalk.* 

Purified  Cotton.  Magnesium  Carbonate.* 

"EmolHent"  and  "demulcent"  are  largely  interchangeable  terms, 
and  no  distinct  division  between  the  substances  used  as  such  can  be 
made.  The  emollient,  demulcent,  and  protective  agents  will,  there- 
fore, be  discussed  here  without  reference  to  the  three  subdivisions 
into  which  they  have  been  grouped. 

GLYCERINUM— U.S.P. 

(Glycerin;  C3H5(OH)3.) 

Glycerin  is  a  syrupy  Hquid  obtained  by  the  decomposition  of 
fats  and  fixed  oils.  It  is  clear,  colorless,  without  odor,  of  a  sweetish, 
warm  taste,  and  when  exposed  to  the  air  slowly  absorbs  moisture. 


GLYCERINUM  II7 

Freely  soluble  in  water  and  alcohol,  but  insoluble  in  ether,  chloro- 
form, and  oils.  Chemically  considered,  it  is  an  alcohol.  Average 
dose  is  I  fl.  dr.  (4.0  mils).     The  following  preparations  are  official: 

Glyceritum  Phenolis,  U.S. P.  (20  per  cent,  of  Phenol). 

Glyceritum  Acidi  Tannici,  U.S. P.  (20  per  cent.  Tannic  Acid). 

Glyceritum  Amyli,  U.S. P.  (Starch,  10;  Water,  10;  Glycerin, 

80). 

Glyceritum  Boroglycerini,  U.S. P.  (50  per  cent,  of  Borogly- 

cerin). 

Glyceritum    Hydrastis,    U.S. P.    (i.o    mils    of   preparation 

contains  i.o  gm.  of  Hydrastis). 

Glyceritum    Ferri,    Quininae,    et    Strychninag    Phosphatum, 

U.S. P.  VIII.     Dose,  10-30  min.  (0.6-2.0  mils). 

Gelatinum  Glycerinatum,  U.S. P.  (equal  parts  of  Gelatin  and 

Glycerin). 

Suppositoria   Glycerini,  U.S. P.  (each  Suppository    contains 

45  gr.-3.o  gm.  of  Glycerin  gelatinized  by  means  of  a  Sodium 

Soap). 

Cataplasma    Koalini,    U.S. P.    VIII.     (Kaolin,  57.7    parts; 

Glycerin,  37.5  parts;  Boric  Acid,  4.5  parts;  Methyl  Salicylate, 

2  parts;  Thymol  and  Oil  of  Peppermint,  each  J'i  part). 

Glycerin  is  also  a  constitiient  of  many  extracts  and  fluid  extracts, 
added  largely  to  preserve  the  preparations. 

Physiologic  Action. — When  glycerin  is  applied  to  sensitive 
skin  or  mucous  membrane,  it  has  a  tendency  to  irritate,  due  to  the 
abstraction  of  water  from  the  tissues.  Taken  internally,  in  large  doses, 
glycerin  acts  as  a  cathartic,  its  action  here  probably  being  due 
also  to  its  hygroscopic  property.  It  is  antiseptic  in  that  it  inhibits, 
to  an  extent,  microorganic  growth.  Authorities  differ  as  to  whether 
or  not  glycerin  in  moderate  doses  acts  as  a  food. 

Therapeutics. — Externally  applied,  glycerin  is  an  efficient  and 
popular  emollient.  For  chapped  hands  and  after  shaving  the  follow- 
ing lotion  is  valuable:  Witch-hazel  and  bay-rum,  each  i  fl.  oz. 
(30.0  mils);  glycerin,  i  fl.  oz.  (30.0  mils);  borax,  }^  dr.  (2.0  Gm.). 
The  formerly  official  cataplasm  of  kaolin,  applied  hot,  is  an  excellent 
substitute  for  ordinary  poultices  where  the  latter  are  indicated.  In 
inflammatory  disease  of  the  mouth,  throat,  and  nose,  glycerin  is  used 
to  advantage  as  a  vehicle  for  other  drugs. 

Glycerite  of  boroglycerin  is  a  constituent  of  many  antiseptic 
mouth-washes;  and  glycerite  of  tannic  acid  may  be  added,  3^  fl.  dr. 
to  the  fl.  oz.  (2.0  mils-30.0  mils),  to  mouth-washes  to  add  astrin- 
gency.  Glycerite  of  tannic  acid  may  also  be  appHed  to  flabby  and 
inflamed  gums.     Glycerin  is  a  constituent  of  the  author's  "pyorrhea 


Il8  EMOLLIENTS,    DEMULCENTS,    AND    PROTECTIVES 

astringent"  (see  p.  429).  It  not  only  depletes  the  engorged  capil- 
laries, but  also  serves  -to  spread  the  drugs  contained  therein  over  the 
entire  surface. 

Internally  it  is  largely  employed  in  habitual  constipation.  Here 
the  official  suppository  may  be  employed. 

Incompatibles. — Powerful  oxidizing  agents,  like  sodium  dioxid, 
chromic  acid,  and  potassium  permanganate,  explode  with  glycerin. 

AMYLUM— U.S.P. 

(Starch;  CeHioOs-) 

Starch  is  a  white  powder,  or  masses,  obtained  from  the  fecula  of 
the  seed  of  Zea  Mays,  or  Indian  corn .  Wheat  starch  (flour)  and  rice 
starch  are  also  used  in  therapeutics.  It  is  insoluble  in  water;  soluble 
in  boiling  water.     There  is  only  one  official  preparation: 

Glyceritum  Amyli,  U.S. P.  (10  per  cent.). 

Therapeutics. — Starch  is  used  externally  in  the  form  of  dusting 
powders  or  "pastes"  as  protective  applications.  It  is  an  antidote 
for  iodin  poisoning,  the  insoluble  starch  iodid  being  formed. 

In  pharmacy  the  glycerite  of  amyl  is  used  as  an  excipient  for 
making  pill-masses  of  certain  drugs. 

OLEUM  OLIViE— U.S.P. 

(OHve  Oil;  Sweet  Oil.) 

Olive  oil  is  a  fixed  oil  expressed  from  the  ripe  fruit  of  Olea  euro  pea, 
a  shrubby  tree  indigenous  to  Western  Asia,  but  cultivated  in  several 
countries,  including  the  southern  part  of  the  United  States,  especially 
California.  The  oil  is  a  pale  yellow  or  light  greenish-yellow  Hquid, 
of  a  characteristic  odor,  and  an  oleaginous  taste.  It  should  be  kept 
in  well-stoppered  bottles,  in  a  cool  place.  The  average  dose  is  i  fl. 
oz.  (30.0  mils). 

Physiologic  Action  and  Therapeutics. — Olive  oil  is  a  bland  and 
agreeable  oil,  and  is  used  extensively  as  an  emollient  and  demulcent. 
It  is  readily  absorbed  from  the  skin  and  mucous  membrane,  and  with 
phenol  (5  per  cent.)  it  makes  a  soothing,  protective  application  for 
superficial  wounds,  bruises,  burns,  insect  bites,  stings,  etc.  Camphor- 
ated olive  oil  (camphor  5  per  cent.)  is  a  useful  remedy  to  rub  on  the 
throat  and  chest  in  cases  of  colds  and  croup  in  children. 

In  cases  of  poisoning  from  corrosive  irritating  drugs,  olive  oil  is  a 
valuable  demulcent,  unless  the  poison  be  soluble  in  an  oil,  in  which 


LIlSrUM — OLEUM  GOSSYPII  SEMESTIS  II9 

case  any  fat  or  oil  is  contraindicated,  as  it  would  tend  to  hasten  the 
absorption  of  the  poison.  Internally  administered,  olive  oil  is  not 
only  demulcent,  but  possesses  marked  nutritive  and  laxative  prop- 
erties.    It  is  often  taken  in  wines  and  liquors  for  its  nutritive  value. 

LINUM— U.S.P. 

(Linseed;  Flaxseed.) 

Linseed  is  the  ground  seed  of  Linum  usitatissimum,  or  common 
flax,  which  is  cultivated  in  all  temperate  countries.  Its  chief  ingre- 
dients are  a  fixed  oil  and  a  mucilaginous  principle.  The  oil  (Oleum 
Lini,  U.S.P.)  is  official,  and  enters  as  an  essential  constituent  into 
the  following  preparations: 

Linimentum  Calcis,  U.S.P. 
Liquor  Cresolis  Compositus,  U.S.P. 

Physiologic  Action  and  Therapeutics. — An  infusion  or  tea  of 
flaxseed  makes  an  excellent  demulcent  drink.  The  ground  flaxseed 
is  probably  used  for  the  ordinary  poultice  in  deep-seated  inflammations 
more  than  any  other  substance.  The  oil  is  similar  to  olive  oil  in 
its  action  and  uses.  Mixed  with  an  equal  quantity  of  Hme-water, 
it  makes  the  official  linimentum  calcis,  commonly  called  carron  oil, 
an  excellent  remedy  for  the  treatment  of  hums.  The  Hniment  of 
soft  soap,  called  tincture  of  green  soap,  should  be  in  every  dental 
ojQ&ce,  and  used  frequently  on  the  hands  for  detergent  purposes, 

OLEUM  GOSSYPH  SEMINIS— U.S.P. 
(Cottonseed  Oil.) 

Cottonseed  oil  is  a  fixed  oil  obtained  from  the  seed  of  cultivated 
varieties  of  Gossypium  herbaceum.  It  occurs  as  a  pale  yellow,  oily 
Hquid,  odorless  or  nearly  odorless,  and  having  a  bland  taste.  It  is 
sHghtly  soluble  in  alcohol;  miscible  with  ether,  chloroform,  and 
petrolatum.  It  enters  as  an  essential  constituent  into  soft  soap. 
which  is  official  (Sapo  MolHs,  U.S.P.);  as  is  also  the  liniment 
of  soft  soap  (Linimentum  Saponis  MolHs,  U.S.P.). 

Physiologic  Action  and  Therapeutics. — Cottonseed  oil  is  used 
for  its  emolHent  and  soothing  properties.  It  has  taken  the  place 
of  Unseed  oil  in  the  U.S.P.  IX  in  the  manufacture  of  soft  soap. 
It  is  also  used  as  a  substitute  for  almond  and  olive  oil,  and  enters 
into  the  composition  of  many  liniments. 


I20  EMOLLIENTS,   DEMULCENTS,    AND   PROTECTIVES 

ADEPS  LAN^— U.S.P. 

(Lanolin;  Wool  Fat.) 

Lanolin,  or  wool  fat,  is  the  purified  fat  of  the  wool  of  sheep, 
freed  from  water.  It  is  a  yellowish-white,  unctuous  substance, 
having  a  faint  pecuHar  odor.  The  Pharmacopeia  also  recognized 
a  wool  fat  which  contains  about  30  per  cent,  of  water  (Adeps  Lanae 
Hydrosus,  U.S.P.). 

Therapeutics. — Lanolin  is  extensively  used  as  a  vehicle  for  oint- 
ments. It  is  bland  and  unirritating,  does  not  become  rancid,  and 
has  the  distinct  advantage  of  being  miscible  with  twice  its  weight 
of  water  without  losing  its  ointment-like  character.  With  this 
vehicle,  therefore,  aqueous  substances  may  be  made  into  ointments. 
It  is  used  as  the  vehicle  for  devitalizing  pastes  for  the  dental  pulp. 
The  hydrous  wool  fat,  in  pharmacy,  is  used  as  a  constituent  in  many 
of  the  ofl&cial  ointments.  It  possesses  the  advantage  over  many 
vehicles  used  for  ointments  in  that  it  is  rapidly  absorbed  by  the  skin, 
thus  carrying  with  it  the  medicaments  contained  therein. 

PETROLATUM— U.S.P. 

(Petroleum  Jelly;  VaseHn.) 

Petrolatum  is  a  mixture  of  hydrocarbons,  chiefly  of  the  methane 
series,  obtained  by  distilHng  off  the  more  volatile  portions  of 
petrole\mi  and  purifying  the  residue.  The  melting-point  should- 
be  between  45°  and  48°C.  Three  forms  are  official:  Petrolatum, 
U.S. P.  (ordinary  petrolatum),  a  yellowish,  ointment-like  mass; 
Petrolatum  Album,  U.S.P.  (white  petrolatum),  a  white  ointment- 
like mass,  and  Petrolatum  Liquidum,  U.S.P.  (liquid  petroleum), 
a  clear,  colorless,  oily  Hquid.  The  latter  is  also  called  Liquid  vaselin 
and  is  known  by  such  trade  names  as  petronol  and  alholin. 

Therapeutics. — Petrolatum  is  bland  and  unirritating,  and  is 
extensively  used  as  an  emolHent  and  protective  dressing.  It  is 
largely  substituted  for  benzolated  lard  in  ointments.  Phenolized 
vaseHn  (3  per  cent,  phenol)  is  a  household  remedy  for  hums,  bruises, 
and  other  excoriations.  An  ointment  made  from  orthoform  (40 
parts)  and  europhen  (60  parts),  with  hquid  vaselin  as  the  vehicle, 
is  a  specific  for  pain  following  the  extraction  of  teeth  where  the  alveolar 
process  has  been  exposed;  it  acts  here  also  as  an  emollient  and  pro- 
tective. Liquid  vaseHn  containing  2  per  cent,  of  menthol  is  an 
excellent  emollient  to  be  used  as  a  spray  in  aciite  coryza. 


paeaffhstum — tragacantea  121 

PARAFFmUM— U.S.P. 
(Paraffin.) 

Paraffin  should  be  discussed  in  connection  with  petrolatum.  It 
is  a  mixture  of  soUd  hydrocarbons  obtained  from  the  same  source. 
It  is  a  white  solid,  and  should  melt  between  51.6°  and  57.2°  C. 

Therapeutics. — Gersung,  in  1900,  recommended  the  subcutane- 
ous and  submucous  injection  of  paraffin  for  the  correction  of  various 
defects  and  for  cosmetic  purposes.  Beck,  of  Chicago,  has  employed 
the  method  quite  extensively  for  the  correction  of  nasal  deformities; 
and  paraffin  has  also  been  injected  about  the  jaws  with  excellent 
results  in  cases  of  necrosis  and  other  diseases  where  hone  tissue  has 
been  lost  or  removed.  The  paraffin  should  be  sterilized  by  boihng  and 
must  be  injected  with  a  specially  prepared  syringe  while  warm  and 
semisolid.  This  substance  when  so  injected  is  not  absorbed,  but 
finally  becomes  encapsulated.  Paraffin  has  also  been  used  for  ffiHng 
root-canals.  It  affords  the  protection  from  moisture  necessary  when 
filling  teeth  with  "plastic  porcelain, "  or  the  various  silicate  cements 
on  the  market;  and  may  also  be  used  to  protect  the  enamel  of  the 
crown  of  the  tooth  when  employing  acids  in  the  canal. 

ACACIA— U.S.P. 

(Gum  Arabic.) 

Acacia  is  a  gummy  exudation  obtained  from  Acacia  Senegal,  and 
other  species  of  Acacia,  a  small  tree,  deeply  and  firmly  rooted,  grow- 
ing in  India,  Africa,  and  other  countries.  It  is  soluble  in  water.  The 
following  preparations  are  official: 

Mucilago  Acaciae,  U.S. P.     Dose,  freely. 
Sjrrupus  Acaciae,  U.S. P.     Dose,  freely. 

Therapeutics. — Acacia  is  used  in  therapeutics  chiefly  for  its 
demulcent  property.  The  mucilage  may  be  further  diluted  with 
water  and  administered  freely  in  cases  of  ■poisoning  from  corrosive 
drugs.  In  pharmacy  it  is  the  emulsifying  agent  generally  employed 
in  making  emulsions  of  oleaginous  drugs;  it  is  also  used  in  pills  and 
lozenges  for  holding  together  the  active  ingredients. 

Incompatibles. — It  is  incompatible  with  alcohol,  ferric  salts,  and 
borax. 

TRAGACANTHA— U.S.P. 

(Tragacanth.) 

Tragacanth  is  a  gummy  exudation  obtained  from  Astragalus 
gummifer,  a  small  shrub  growing  in  Western  Asia.     This  gum  differs 


122  EMOLLIENTS,    DEMULCENTS,    AND    PROTECTIV^ES 

from  acacia  in  that  it  does  not  dissolve  in  water,  but  swells  up  in  it  and 
forms  a  gelatinous  mass.  The  of&cial  preparation  is: 
Mucilago  Tragacanthae,  U.S. P. 
Therapeutics. — Though  possessing  demulcent  properties,  it  is 
impracticable  to  use  it  as  such  on  account  of  its  insolubility.  The 
mucilage  of  tragacanth  may  be  used  as  an  emollient  in  chapped  hands 
and  other  skin  lesions.  In  pharmacy  it  is  used  for  suspending  resin- 
ous and  oleaginous  drugs  in  water;  it  also  enters  into  most  of  the 
official  troches. 

GLYCYRRHIZA— U.S.P. 

(Licorice  Root.) 

Glycjnrhiza  is  the  dried  rhizome  and  root  of  Glycyrrhiza  glabra,  or 
Glycyrrhiza  glandulifera,  a  perennial  herb  growing  in  the  countries 
lying  on  the  northern  and  southern  shores  of  the  Mediterranean  Sea ; 
also  cultivated  in  England  and  the  United  States.  It  contains  a 
glucosid,  glycyrrhizin,  to  which  is  due  its  sweetish  taste;  it  also  con- 
tains an  acrid  resin,  starch  and  gum.  The  following  preparations 
of  licorice  are  official: 

Fluidextractum   Glycyrrhizje,   U.S. P.     Dose,    15-60   min. 

(1.0-4.0  mils). 

Extractum    Glycyrrhizas,    U.S. P.     Dose,  freely. 

Extractum  Glycyrrhizae  Purum,  U.S. P.     Dose,  freely. 

Mistura  Glycyrrhizae  Composita,  U.S.P.     Dose,  1-4  fl.  dr. 

(4.0-16.0  mils). 

Piilvis  Glycyrrhizas  Compositus,  U.S.P.     Dose,  3^-2  dr. 

(2.0-8.0  Gm.). 

Elixir  Glycyrrhizae  (from  Fluidextract),  U.S.P.     Dose,  freely. 

Glycyrrhizinum  Ammoniatum,  U.S.P.     Dose,  4  gr.  (0.25  Gm.). 

Physiologic  Action  and  Therapeutics. — ^Licorice  root  is  demul- 
cent and  slightly  laxative,  and  when  chewed  increases  the  flow  of 
saHva.  It  sHghtly  stimulates  and  favors  the  secretion  of  mucus  in 
the  respiratory  passages.  It  is  a  popular  remedy  for  cough,  sore 
throat,  and  hoarseness.  It  is  found  in  many  of  the  pharmaceutic 
preparations,  and  may  be  used  to  advantage  in  masking  the  taste  of 
nauseating  drugs.  The  official  fluid  extract,  the  extract,  and  the 
syrup  (N.  F.)  are  largely  used  for  this  latter  purpose. 

ALTILEA— U.S.P. 
(Marshmallow  Root.) 

Marshmallow  is  the  dried  root  of  Althcea  officinalis,  a  perennial 
herb  growing  in  most  countries  with  a  temperate  cHmate.  Its  chief 
constituents  are  mucilage,  sugar,  and  starch. 


SASSAFRAS  MEDULLA— CO LLODIUM  1 23 

Physiologic  Action  and  Therapeutics. — Marshmallow  is  emol- 
lient, demulcent,  and  protective,  and  may  be  employed  as  such  in  all 
irritable  and  inflamed  conditions  of  the  mucous  membrane  and  skin. 

SASSAFRAS  MEDULLA  (Nonofficial) 
(Sassafras   Pith.) 

Sassafras  is  the  dried  pith  obtained  from  the  branches  of  Sassafras 
variifolium,  a  tree  indigenous  to  North  America.  Both  the  drug  and 
mucilage  of  sassafras  were  official  in  the  U.S. P.  VIII. 

Physiologic  Action  and  Therapeutics. — Mucilage  of  sassafras 
pith  is  a  pleasant  demulcent,  and  may  be  used  wherever  such  is  indi- 
cated. An  infusion  or  tea  made  from  the  bark  of  the  root  of  the 
sassafras  tree  has  long  been  a  domestic  remedy  as  a  "spring  tonic." 

ULMUS— U.S.P. 

r 

(SHppery    Elm.) 

Slippery  elm  is  the  dried  inner  bark  of  Ulmus  fulva,  a  large  tree 
growing  in  the  United  States  and  Canada.  It  contains  much  muci- 
laginous matter. 

Physiologic  Action  and  Therapeutics. — The  mucilage  of  elm,  for- 
merly official,  is  a  decided  demulcent,  and  is  supposed  to  possess 
nutritive  properties.  It  is  pleasant  to  the  taste,  and  generally  does 
not  disturb  the  stomach.  It  is  especially  useful  after  washing  out 
the  stomach  for  any  purpose.  In  the  form  of  troches  (elm  lozenges), 
it  is  useful  as  a  soothing  agent  in  irritated  or  sore  throat. 

COLLODIUM— U.S.P. 

(CoUodion.) 

Collodion  is  a  solution  of  pyroxyhn,  or  gun  cotton,  4,  in  ether  75, 
and  alcohol  25  parts.  It  is  a  colorless,  syrupy  hquid,  highly  inflam- 
mable, and  having  a  strong  ethereal  odor.  The  following  prepara- 
tions are  official: 

CoUodium  Flexile,  U.S.P. 

CoUodium  Cantharidatum,  U.S.P.   (Blistering  CoUodion; 

Cantharides,  60  per  cent.). 

Therapeutics. — When  applied  to  the  skin,  collodion  quickly  dries 
and  forms  a  thin  film,  which  not  only  protects  an  exposed  part,  but 
produces  shght  compression.  It  therefore  makes  an  excellent  pro- 
tective for  aseptic  wounds,  fissures,  and  punctures.     This  agent  affords 


124  EMOLLIENTS,    DEMULCENTS,    AND    PROTECTIVES 

an  efficient  means  of  securing  neat  antiseptic  dressings  on  dentists' 
hands  which  may  be  abraded  or  punctured  by  instruments.  The 
wound,  if  necessary,  can  be  cauterized  with  phenol  or  silver  nitrate, 
and  then  covered  with  an  antiseptic  powder  like  europhen  or  boric 
acid;  this  should  be  covered  with  absorbent  cotton  and  the  dressing 
retained  with  collodion.  Thus  treated,  the  wound  is  well  protected 
and  should  heal  by  first  intention.  The  flexible  collodion  cracks 
less  readily  than  the  plain  collodion,  and  may  be  used  if  desired. 

Styptic  collodion  was  formerly  official  and  contained  20  per  cent, 
of  tannic  acid.  When  applied  to  small  wounds,  hke  cold-sores  on  the 
lip,  it  will  check  capillary  oozing.  Cantharidal  or  blistering  collodion 
may  be  used  as  a  counterirritant  in  pericemental  inflammations  and 
neuralgias. 

Gutta-perchse  (nonofficial). — Gutta-percha  is  a  milky,  concrete 
exudation,  occurring  in  several  species  of  the  gutta  tree,  which  is  indig- 
enous to  the  Malay  Archipelago,  Sulu  Islands,  and  Java ;  recently  it 
was  learned  that  the  gutta  tree  grows  abundantly  in  the  Philippine 
Islands.  When  pure,  gutta-percha  has  a  specific  coloring  between 
pink  and  grayish-white.  Single  pieces  are  not  adhesive  at  ordinary 
temperatures,  but  heated  slightly  and  pressed  together  the  piece^ 
adhere  and  cannot  be  separated.  Gutta-percha  is  insoluble  in  water 
and  alcohol,  but  soluble  in  chloroform,  eucal3^tol,  and  cineol. 

Therapeutics. — Gutta-percha  dissolved  in  chloroform  may  be 
used  as  a  protective  for  small  wounds.  It  has  also  been  employed  as 
a  means  of  retaining  antiseptic  and  other  dressings  in  the  canals  of 
teeth.  For  this  purpose  it  does  not  exclude  the  bacteria-laden  saliva, 
and  should  be  discarded.  The  solution,  known  as  chloropercha,  has 
long  been  successfully  used  in  moistening  the  dried  canal  previous  to 
filling  with  a  gutta-percha  cone.  The  author  suggests  heating  the 
.white  base-plate  gutta-percha  in  eucalyptol  (see  p.  360),  when  a 
thick,  creamy  solution  results,  which  becomes  a  soft  soHd  when  cold. 
This  preparation  is  used  in  filling  root-canals,  as  will  be  explained  in 
Practical  Therapeutics.  Cochran  suggests  making  a  saturated  solu- 
tion of  thymol  in  eucalyptol,  and  after  cutting  the  gutta-percha  with 
chloroform  mixing  the  two  solutions,  permitting  the  chloroform  to 
evaporate,  when  a  soft  solid  results  which  is  used  in  filling  root-canals. 

TALCUM  PURIFICATUM— U.S.P. 

(Purified  Talc;  Magnesium  Silicate;  Soapstone.) 

Purified  talc  is  a  native,  hydrous  magnesium  silicate,  and  occurs 
as  a  very  fine,  white,  or  grayish-white  powder,  which  adheres  to  the 


KAOLESrUM — LYCOPODIUM  1 25 

skin.  It  feels  greasy  to  the  touch,  hence  it  is  commonly  called 
soapstone.  The  Pharmacopeia  suggests  using  purified  talc  in  the 
preparation  of  essential  oil  waters. 

Therapeutics. — Finely  powdered  talc  is  employed  as  a  dusting 
powder  in  inflammatory  diseases  of  the  skin,  such  as  acute  erythema- 
tous eczema.  A  useful  formula  is:  Pulverized  talc,  4  dr.  (16.0  Gm.); 
zinc  oxid,  3  dr.  (12.0  Gm.);  boric  acid,  i  dr.  (4.0  Gm.).  This  powder 
is  also  useful  in  chafing.  Many  of  the  commercial  talcum  powders 
contain  talc  and  boric  acid  in  varying  proportions.  Talc,  or  soap- 
stone,  is  used  in  dentistry  also  to  coat  the  model  so  that  it  will  draw 
nicely  from  the  moulding  sand  in  making  a  metal  die. 


KAOLmUM  (Nonofficial) 
(Fuller's  Earth;  Hydra  ted  Aluminum  SiUcate.) 

Kaolin  is  a  native  aluminum  silicate,  occurring  as  a  soft,  white, 
or  yellowish-white  powder,  odorless,  and  having  an  earthy  or  clay- 
like taste.  It  is  insoluble  in  water,  but  becomes  unctuous  when 
moist.  It  is  a  very  pure  clay,  having  the  chemic  formula,  H2Al2Si208.- 
H2O. 

Therapeutics. — The  cataplasm,  formerly  official,  is  used  as  a 
poultice,  applied  hot,  in  mild  local  infections  about  the  face  and  jaws. 
Kaolin  is  also  used  in  dusting  powders,  and  is  a  constituent  of  porce- 
lain body.  In  pharmacy  it  is  used  in  pills  containing  easily  reduced 
drugs,  like  silver  nitrate  and  potassium  permanganate,  which  cannot 
be  mixed  with  the  ordinary  pill  excipients. 

LYCOPODIUM— U.S.P. 

Lycopodium  is  the  spores  of  Lycopodium  clavatum  and  other 
species  of  Lycopodium,  mosses  growing  in  nearly  all  temperate  coun- 
tries. It  is  a  fine  powder,  pale  yellow  in  color,  very  mobile,  nearly 
inodorous,  tasteless,  floats  upon  water  and  is  not  wetted  by  it,  and 
burns  quickly  when  thrown  into  a  flame. 

Therapeutics. — ^Lycopodium  is  employed  in  therapeutics  as  a 
protective.  It  possesses  great  absorbent  power  for  oils,  which,  to- 
gether with  its  dryness  and  lightness,  renders  it  an  excellent  dusting- 
powder  for  superficial  ulcers,  eczema,  etc.  In  dentistry  it  is  also  used, 
like  soapstone,  for  coating  models  in  making  dies;  and  in  pharmacy 
it  is  employed  to  prevent  the  adhesion  of  newly-made  pills  and 
suppositories. 


126  LOCAL   ANESTHETICS 

In  the  discussion  of  drugs  thus  far,  the  author  has  endeavored 
to  group  them,  as  far  as  was  possible,  into  local  and  general  remedies. 
Those  which  have  been  considered  are  employed  largely  in  thera- 
peutics for  their  local  effects  upon  the  skin  and  mucous  membranes  of 
the  respiratory  and  alimentary  passages.  The  consideration  of  the 
next  group,  local  anesthetics,  will  naturally  lead  us  into  the  discussion 
of  general  anesthetics,  and  from  then  on  general  remedies  will  be 
considered. 

ANESTHETICS 

Anesthetics  have  been  elsewhere  defined  as  agents  which  tempo- 
rarily destroy  sensation.  They  are  subdivided  into  two  classes:  (i) 
Those  which  produce  local  anesthesia;  and  (2)  those  which  produce 
general  anesthesia.  By  local  anesthesia  is  meant  the  abolition  of  sen- 
sibility to  pain  in  a  part;  general  anesthesia  means  the  abolition  of  all 
sensibility,  including  unconsciousness.  In  the  administration  of 
general  anesthetics,  the  patients  experience  a  stage  where  they  are 
insensible  to  pain,  though  not  unconscious.  This  condition  is  known 
as  analgesia,  which  means  the  absence  of  sensibility  to  pain.  Agents 
which  produce  the  condition,  whether  general  anesthetics,  like  nitrous 
oxid,  chloroform  or  ether,  or  other  drugs,  such  as  opium,  the  coal-tar 
derivatives — antipyrin,  acetanilid,  and  phenacetin — the  bromids, 
chloral,  etc.,  are  called  analgesics.  Closely  associated  with  these 
drugs  is  the  term  anodyne,  which  means  an  agent  that  relieves  pain. 
An  anodyne  effect  presupposes  the  presence  of  pain,  an  analgesic 
effect  does  not;  it  simply  means  that  pain  cannot  be  experienced. 
Many  drugs  possess  local  anodyne  properties,  such  as  many  volatile 
oils,  phenol,  cresol,  etc. 

LOCAL  ANESTHETICS 

Local  anesthetic  agents  may  be  conveniently  subdivided  into 
two  classes,  according  to  the  mode  of  action  by  which  the  anesthetic 
effect  of  the  drug  is  produced. 

1.  Refrigerant.' — Those  agents  which  produce  a  degree  of  cold 
by  the  abstraction  of  heat  from  the  part  to  which  they  are  applied, 
even  to  the  point  of  freezing  the  tissue. 

2.  Paralyzant. — Those  agents  which,  when  appHed  locally,  have 
a  direct  paralyzant  action  upon  the  sensory  nerve  terminals. 

Refrigerant.  Paralyzant. 

Ethyl  Chlorid  Spray.  Cocain. 

Ether  Spray.  Tropacocain. 


^THYLIS  CHLOREDUM  1 27 


Rhigolene  Spray. 

Eucain. 

Ice. 

Novocain. 

Neothesin. 

Chloretone, 

Orthoform. 

^THYLIS  CHLORIDUM— U.S.P. 

(Ethyl  Chlorid;  Kelene;  C2H5CI.) 

Ethyl  chlorid  is  prepared  by  the  action  of  hydrochloric  acid  gas 
upon  absolute  ethyl  alcohol,  the  hydroxyl  radical  in  the  latter  being 
replaced  by  chlorin.  It  occurs  as  a  colorless,  extremely  volatile 
liquid,  having  an  odor  resembling  that  of  chloroform  and  a  burning 
taste.  The  vapor  is  highly  inflammable,  and  it  should  not  he  used 
near  a  gas- flame  or  burning  alcohol-lamp. 

Physiologic  Action.- — Applied  locally  by  means  of  a  spray, 
ethyl  chlorid  acts  as  a  refrigerant  local  anesthetic,  the  tissues  soon 
becoming  white  and  superficially  frozen  from  the  abstraction  of  heat. 

The  drug  may  be  inhaled  from  gauze  or  a  specially  devised  in- 
haler which  is  adjusted  to  the  face,  when  it  acts  as  a  general  anes- 
thetic. The  anesthesia  is  usually  accompanied  by  a  fall  of  arterial . 
pressure  and  a  gradual  decrease  in  the  pulse-rate,  due  in  all  proba- 
bility to  a  direct  action  upon  the  heart.  The  patient  becomes 
anesthetized,  as  a  rule,  in  from  i  to  3  minutes,  and  from  1-2  fl.  dr. 
(4  0-8.0  mils)  of  the  drug  being  required,  depending  upon  the  patient. 
Its  action  is  rapid  and  unirritating  to  the  mucous  membrane  of  the 
respiratory  passages;  there  is  an  absence  of  choking  sensation  or 
cyanosis;  and  but  rarely  does  nausea  or  vomiting  follow.  The 
recovery  is  generally  complete  in  from  2  to  5  minutes. 

Therapeutics. — Ethyl  chlorid  is  usually  sold  in  small  metallic 
or  glass  tubes,  provided  with  a  lever-spring  or  screw  top.  When 
the  lever  is  depressed  or  the  screw  released,  the  liquid  is  expelled  as 
a  spray  by  the  heat  of  the  hand.  This  drug  is  a  safe  and  convenient 
local  anesthetic  for  minor  operations  requiring  but  a  single  incision, 
as  in  the  lancing  of  abscesses,  boils,  etc.,  or  for  the  extraction  of  loose 
teeth.  Its  local  anesthetic  action  is  not  sufficiently  profound  to 
permit  the  painless  extraction  of  firmly  attached  teeth.  There  is 
very  little  danger  attending  the  local  use  of  the  drug  from  inhalation. 

The  drug  may  be  used  as  a  general  anesthetic  for  minor  surgical 
operations  necessitating  the  administration  of  a  general  anesthetic. 
Ethyl  chlorid  is  a  constituent  of  many  commercial  products  sold  for 
general  anesthetic  purposes,  among  which  may  be  mentioned 
somnoform,  narcotile,  etc. 


128  LOCAL   ANESTHETICS 

As  a  general  anesthetic,  ethyl  chlorid  has  the  one  advantage  over 
nitrous  oxid,  or  nitrous  oxid  and  oxygen,  of  not  requiring  a  cumber- 
some apparatus  for  its  administration,  but  its  safety  cannot  be  com- 
pared with  that  of  nitrous  oxid.  Though  the  drug  has  only  been 
used  a  few  years  as  a  general  anesthetic,  quite  a  number  of  deaths 
from  its  use  have  been  reported. 

Ether  Spray. — Ether,  or  ether  and  alcohol,  in  the  form  of  a 
spray,  has  been  suggested  as  a  means  of  desensitizing  dentin.     It  acts, 
as  a  refrigerant  local  anesthetic. 

Rhigolene  Spray. — Rhigolene  is  an  unof&cial  distillate  of 
petroleum.  It  may  be  used  as  a  spray  for  the  same  purpose  as 
ether,  but  has  no  advantages  over  the  latter. 

Ice. — Ice,  or  the  ice  and  salt  mixture,  was  probably  the  first  of 
all  local  anesthetics.  Though  its  use  is  largely  superseded,  espe- 
cially in  the  mouth,  by  the  volatile  liquids,  like  ether  and  ethyl 
chlorid,  it  still  has  a  place  of  usefulness  upon  accessible  surfaces. 

An  ice-poultice  may  be  made  by  sewing  up  tightly  in  rubber 
cloth  crushed  ice  mixed  with  salt  and  sawdust,  bran,  or  ground  flax- 
seed. Local  appHcations  of  cold  in  this  manner  abstract  heat  from 
the  part,  lessen  the  sensibiHty  of  the  peripheral  nerve-filaments, 
cause  constriction  of  the  blood-vessels  traversing  the  tissues  exposed 
to  the  cold,  and  by  reflex  action  affect  the  vascularity  of  the  parts 
subjacent  to  the  site  of  application. 

COCA  (Nonofficial) 

Coca  is  the  dried  leaves  of  Erythroxylon  coca,  a  plant  growing  in 
the  mountainous  regions  of  Peru,  Bolivia,  and  other  South  American 
states.  It  contains  a  number  of  alkaloids,  the  most  important  being 
cocain,  which  is  official  both  as  the  alkaloid  and  alkaloidal  salt 
under  the  titles,  respectively,  Cocaina  and  Cocaince  Eydrochloridum. 

The  general  rule  adopted  by  the  United  States  Pharmacopeia  in 
the  nomenclature  of  articles  of  botanical  origin  is  for  the  Latin  title 
to  be  the  genus  name  of  the  plant  and  not  the  species.  Coca,  which 
was  official  in  the  U.S. P.  VIII,  is  a  notable  exception  to  this  rule;  for 
instead  of  calling  this  article  Erythroxylon  it  was  officially  designated 
Coca.  While  the  early  generic  names  of  plants  were  selected  rather 
arbitrarily,  the  differentiation  of  their  species  is  almost  invariable 
indicated  in  their  specific  names;  yet  some  of  the  native  plant  names 
lead  to  great  confusion.  Students  frequently  confuse  the  names 
cocoa  (cacao),  coco  (nut),  and  coca,  three  separate  and  distinct 
plants.     When  Von   Humboldt  discovered   the   chocolate  nut  he 


COCAINA — COCAINE  HYDROCHLORIDUM  1 29 

named  it  Theobroma  (meaning  God's  drink)  and  cacao,  after  the 
native  Indian  name;  but  it  has  always  been  confused,  because  of  the 
similarity  of  names,  with  the  Cocos  nucifera,  the  milk-bearing  cocoa- 
nut;  and  by  many  to-day  the  oil  of  theobroma  is  called  cocoa-butter 
instead  of  cacao.  It  should  be  remembered  that  coca  is  the  name 
for  the  plant,  from  the  leaves  of  which  that  valuable  alkaloid,  cocain 
is  obtained.     There  are  now  no  official  preparations  of  this  drug. 

COCAINA— U.S.P. 
(Cocain;  C17H21NO4.) 

Cocain  occurs  in  the  form  of  colorless,  prismatic  crystals,  having 
the  bitter  taste  characteristic  of  all  alkaloids,  and  producing  on  the 
tongue  a  temporary  numbness.  It  is  sparingly  soluble  in  water 
(1-600  parts),  much  more  so  in  alcohol  (1-6.5  parts),  more  readily 
in  both  when  warm,  in  ether  (1-3.5),  ^^^  i^  the  oils  (about  1-12). 
The  average  dose  is  about  3^^  gr.  (0.016  Gm.). 

COCAINE  HYDROCHLORIDUM— U.S.P. 

(Cocain  Hydrochlorid;  C17H21NO4.HCI.) 

Cocain  hydrochlorid,  called  previous  to  the  U.S.P.  of  1900 
cocain  hydrochlorate,  occurs  in  the  form  of  colorless  prisms,  lustrous 
leaflets  or  flakes,  or  crystalline  powder.  This  alkaloidal  salt,  like 
the  alkaloid  itself,  has  a  bitter  taste,  and  leaves  a  temporary  numb- 
ness on  the  tongue.  It  is  freely  soluble  in  water  (1-C.4  part), 
somewhat  less  so  in  alcohol  (1-3.2  parts);  soluble  in  glycerin  and 
insoluble  in  ether  and  oils. 

The  amount  to  be  injected  h)^odermically  at  one  time  should 
not  exceed  M  to  3^  gr.  (0.016-0.03  Gm.). 

Brief  History. — It  may  be  stated  as  a  matter  of  history  that  the 
introduction  of  cocain  to  the  medical  and  dental  world  was  due  to 
Koller,  of  Vienna,  who,  in  1884,  reported  his  experiments  with  the 
drug  to  the  Congress  of  German  Oculists,  In  a  few  weeks  cocain 
or  the  alkaloidal  salt,  cocain  hydrochlorid,  was  being  used  as  a  local 
anesthetic  all  over  the  world.  Among  the  men  whose  names  should 
be  mentioned  as  early  investigators  are  the  following:  Hepburn, 
Biggs,  Hall,  Halsted,  Rudolph  Matas,  J.  L.  Corning,  and  C.  P. 
Pruyn.  Hall,  in  1884,  demonstrated  by  an  experiment  upon 
himself  that  he  could  inject  solutions  of  cocain  hydrochlorid  into 
the  infraorbital  nerve  and  anesthetize  the  teeth.  Halsted,  in  the 
following  year,  1885,  and  some  gentlemen  in  South  America  about 


I30 


LOCAL    ANESTHETICS 


the  same  time,  not  knowing  that  Halsted  was  working  along  the 
same  line,  demonstrated  that  they  could  inject  9  min.  of  a  4  per 
cent,  solution  into  the  inferior  dental  nerve  as  it  jentered  the  inferior 
dental  canal,  and  produce  complete  anesthesia  of  the  gums  and 
teeth  on  that  side  of  the  jaw.  This  method  is  known  to-day  as  ' '  nerve 
blocking"  or  conductive  anesthesia.  It  was  about  this  time  that 
Pruyn,  of  Chicago,  conducted  a  long  series  of  experiments  on  dogs, 
and  to  him  much  credit  is  due  for  the  high  place  which  cocain  occu- 
pies in  dental  practice  to-day.  In  speaking  of  these  experiments, 
Pruyn^  says:  "The  first  dog  that  I  experimented  on,  and  sub- 
sequently killed,  made  me  shudder  to  see  the  poor  animal  in  the 
throes  of  d^d^th.  fighting  for  his  breath.  It  made  an  impression  on  me 
that  has  lasted  ever  since,  and  taught  me  that  cocain  should  be 
handled  very  carefully,  particularly  when  we  are  using  it  upon  the 
human  subject."  Therefore,  the  alarming  symptoms  and  the  fre- 
quent fatalities  which  followed  the  early  use  of  cocain  caused  it  for 
a  time  to  be  barred  from  general  use  in  general  and  dental  surgery. 
The  fact,  however,  that  many  patients  objected  to  general  anesthetics 
on  account  of  the  unconsciousness  induced,  and  the  further  fact  that 
every  conscientious  surgeon  recognized  that  a  certain  amount  of 
danger  always  attends  the  administration  of  general  anesthetics 
were  sufi&cient  to  cause  a  few  men  to  experiment  further  with  the 
drug.  They  diminished  the  strength  of  the  solution,  and  gradually 
mastered  the  technic  of  its  administration  until  alarming  symptoms 
and  fatalities  became  very  infrequent. 

Physiologic  Action.' — Whatever  effects  result  from  the  admin- 
istration of  preparations  of  coca  are  due  entirely  to  the  alkaloids 
contained  therein.  Cocain  is  a  t3^ical  local  anesthetic  of  the 
paralyzant  group.  When  the  drug  enters  the  circulation  its  first 
action  is  that  of  a  stimulant,  followed  shortly  by  a  depressant  effect. 
It  is  a  general  protoplasmic  poison,  and  acts  deleteriously  upon  all 
kinds  of  tissue.  It  has  been  supposed  that  the  drug  acts  more 
prominently  upon  nerve  tissue,  but  such  is  not  the  case.  It  is  true 
that  its  action  is  more  discernible  upon  nerve  tissue  for  the  reason 
that  this  tissue  is  the  medium  of  sensation  and  expression.  When 
appUed  locally  or  injected  beneath  the  mucous  membrane  or  skin, 
its  depressant  action  on  the  sensory  nerve  filaments  is  sufficiently 
profound  to  induce  complete  local  anesthesia  or  analgesia.  It  is 
also  a  powerful  vaso-constrictor;  the  ischemia  produced,  however, 
is  ultimately  followed  by  congestion. 

Long  before  the  drug  was  used  as  a  medicine,  the  natives  of 

1  Dental  Review,  Vol.  16,  p.  312. 


COCAINiE  HYDEOCHLORIDUM 


131 


South  America  learned  that  by  eating  the  leaves  of  the  coca  plant 
they  could  travel  for  days  through  the  deserts  without  experiencing 
the  sensation  of  hunger.  We  now  know  that  the  cocain  paralyzed 
the  nerve  filaments  which  control  the  appetite. 

Poisoning  and  Treatment. — The  symptoms  of  acute  cocain  poison' 
ing  are   rather   variable.     The  usual  manifestations    are  nervous 


Fig.  I. — Artificial  Respiration.     First  Movement. 

excitement,  followed  by  delirium,  and  later  by  drowsiness  and 
stupor;  nausea,  vomiting,  a  rapid  pulse,  hurried  and  difficult  respira- 
tion, dilatation  of  the  pupils,  cold  sweat,  blanched  expression,  blue 
lips,  convulsive  seizures,  and  finally  death  through  asphyxia. 


Fig.  2. — Artificial  Respiration.     Second  Movement. 


Individuals  differ  widely  in  their  susceptibility  to  cocain.  The 
local  application  of  even  moderate  solutions  of  the  drug  to  the  nose 
or  throat  in  some  subjects  is  followed  by  toxic  symptoms.  Some 
have  a  peculiar  idiosyncrasy  for  cocain.  Cases  have  been  authenti- 
cally reported  where  the  drug  was  not  used,  but  where  the  patient 


132  LOCAL   ANESTHETICS 

supposed  it  had  been,  and  exhibited  the  usual  toxic  symptoms 
in  mild  form. 

There  is  no  known  antidote  for  cocain;  therefore,  the  treatment 
of  poisoning  is  purely  symptomatic.  When  the  symptoms  are 
rather  mild  the  patient  should  be  kept  in  a  recumbent  position,  the 
head  lower  than  the  feet,  if  possible  (the  modern  dental  chair  makes 
this  possible),  and  such  stimulants  given  as  whisky,  brandy,  and 
aromatic  spirit  of  ammonia,  15-20  min.  (i. 0-1.3  mils)  of  the  latter 
in  a  small  quantity  of  water.  The  irritation  of  the  ammonia  is 
what  is  desired,  and  it  is  best  here  not  to  dilute  the  drug  too  much. 
Spirit  of  ammonia  or  spirit  of  camphor  may  be  given  by  inhalation. 
Ammonia  irritates  the  mucous  membrane,  and  thus  directly  stimu- 
lates the  heart.  When  the  s3miptoms  are  more  pronounced,  espe- 
cially when  the  patient  is  unable  to  swallow  and  a  direct  cardiac 
stimulant  is  required,  strychnin  is  the  drug  to  administer.  This 
may  be  given  hypodermically  in  the  form  of  strychnin  sulphate,  the 
injection  being  made  in  the  arm  or  cellular  tissue  of  the  lumbar 
region.  One-thirtieth  grain  (0.0025  gm.)  may  be  administered  at 
a  time  and  repeated  every  15  minutes,  if  occasion  requires,  until 
3  injections  are  made.  When  there  is  danger  of  respiratory  failure 
atropin  sulphate  in  from  M.20~}'60  gr.  (0.0005-0.001  Gm.)  should  be 
given.  As  a  last  resort  to  prevent  asphyxia,  artificial  respiration 
should  be  performed.  Sylvester's  method  is  the  one  most  commonly 
employed.     Figs,  i  and  2  show  the  position  of  patient  and  attendant. 

With  the  patient  placed  on  his  back,  on  a  flat  surface,  supporting 
the  head  and  shoulders  with  a  cushion  or  articles  of  dress,  all  tight 
clothing  should  be  loosened  or  removed  from  the  neck  and  chest. 

The  movements  of  inspiration  and  expiration  should  regularly 
succeed  each  other  at  the  rate  of  from  20  to  25  respirations  per 
minute,  or  slightly  in  excess  of  the  normal  rate  (about  18  per  minute). 
The  inspiratory  period  should  be  sHghtly  longer  than  the  expiratory. 
In  all  cases  artificial  respiration  should  be  continued  until  natural 
respiration  is  established.  This  may  require  hours,  and  necessi- 
tate a  relay  of  assistants.  In  the  treatment  of  poisoning  of  any 
kind  the  operator  should  avoid  the  appearance  of  excitement,  and 
remember  that  as  long  as  there  is  life  there  is  a  chance  of  recovery. 

Habit. — Cocain  is  one  of  the  most  seductive  of  the  drugs  that  are 
taken  habitually,  and  its  effects  are  most  disastrous.  A  potent  cause 
of  the  cocain  habit  has  been  the  frequent  use  of  the  drug  in  diseases  of 
the  nose  and  throat.  As  the  drug  is  used  in  dentistry  there  is  Httle 
chance  of  producing  the  habit;  yet  it  is  very  unwise  to  prescribe  the 
drug  to  be  used  by  the  patient  at  home  in  the  form  of  toothache  reme- 


COCAINE  HYDROCHLORIDUM  1 33 

dies,  mouth-washes,  gargles,  or  nasal  sprays.  Cocain  is  one  of  the 
drugs  that  come  under  the  "Federal  Narcotic  Law;"  and  whenever 
ordered  or  prescribed,  it  must  be  done  on  a  "record  blank"  furnished 
by  the  United  States  Government.  The  chief  symptoms  of  the 
cocain  habit  are  emotional  excitement,  physical  unrest,  mental  im- 
pairment, a  disregard  for  morals,  hallucinations,  gastric  disturbances, 
a  gradual  wasting  away,  and  anemia. 

Therapeutics. — There  is  a  demand  by  the  laity  for  painless 
dentistry,  and  no  one  drug  aids  the  dentist  more  in  meeting  this  de- 
mand than  cocain  or  its  alkaloidal  salt,  cocain  hydrochlorid.  The 
drug  is  extensively  used  in  the  painless  extraction  of  teeth,  lancing  of 
abscesses,  removal  of  vital  dental  pulps,  and  many  other  conditions. 
Cocain  hydrochlorid  is  recommended  in  cases  of  nausea  in  taking  im- 
pressions. Goslee  suggests  using  a  2  per  cent,  solution  in  an  atom- 
izer, spraying  the  entire  palate  and  the  uvula.  A  glass  of  tepid 
water  should  be  at  hand  and  the  patient  may  rinse  the  mouth  after  a 
few  seconds,  to  avoid  swallowing  the  solution.  The  spraying  process 
may  be  repeated  about  every  five  minutes  until  two  or  three  applica- 
tions have  been  made. 

Cocain  is  also  added  to  many  arsenical  preparations  to  control  the 
irritating  action  of  the  arsenic  trioxid.  If  the  vehicle  for  such  prepa- 
rations is  an  oil,  the  alkaloid  should  always  be  used,  as  the  alkaloidal 
salt  is  insoluble  in  oils. 

The  formerly  official  oleate  (5  per  cent,  of  the  alkaloid)  may  be 
used  to  lessen  the  pain  in  setting  crowns  and  bridges.  This  is  done 
by  applying  the  remedy  under  the  margin  of  the  gum  a  few  minutes 
before  setting  the  crown.  Cocain  hydrochlorid  is  used  more  exten- 
sively by  the  hypodermic  method  of  administration  for  the  painless 
extraction  of  teeth  than  for  any  other  purpose  in  dentistry.  A  brief 
discussion,  therefore,  of  the  hypodermic  use  of  the  drug  will  here  be 
considered. 

Sodium  chlorid  has  been  recommended  by  Schleich  and  others 
as  an  excellent  agent  to  be  added  to  local  anesthetic  solutions  for  two 
reasons:  One  is  that  it  aids  in  the  elimination  of  the  drug,  and  the 
other,  and  more  important,  is  that  with  it  isotonic  solutions  can  be 
prepared  with  local  anesthetics  as  the  base.  The  action  of  the  so- 
called  "salt  solutions"  will  be  discussed  under  Cathartics  (which  see, 
p.  215).  Transitory  anesthesia  can  be  produced  ultimately  by  pres- 
sure, or  by  simply  injecting  with  force  distilled  water  into  the  gum 
tissue;  but  distilled  water  being  hypoiso tonic  to  the  normal  fluids 
in  the  tissues,  its  injection  causes  a  temporary  swelling  of  the  cells, 
due  to  osmotic  action,  and  primary  pain  is  produced.     On  the  other 


134  LOCAL    ANESTHETICS 

hand,  the  injection  of  a  hj^perisotonic  solution  causes  a  temporary 
condensation  of  the  cells,  due  also  to  osmosis,  and  primary  pain  is 
produced.  If,  therefore,  isotonic  solutions  are  employed  for  the  pur- 
pose of  inducing  local  anesthesia,  osmotic  action  is  avoided,  and  the 
relation  of  the  cells  to  each  other  is  not  materially  affected.  Prinz 
suggests  adding  sodium  chlorid  in  the  following  proportion  in  making 
an  isotonic  solution  of  cocain  hydrochlorid : 

Cocain  Hydrochlorid,  5  gr.  (0.3  Gm.) 

Sodium  Chlorid,  4  gr.  (0.25  Gm.) 

Distilled  Water,  i  fl.  oz.  (30.0  mils) 

To  each  syringeful  (30  min.-2.o  mils)  add  one  minim  (0.065  i^iO 
of  a  I- 1 000  solution  of  adrenahn  chlorid  when  used.  The  adrenahn 
solution  should  be  fresh.  The  technic  of  making  the  injection  has 
been  fully  discussed  under  the  Hypodermic  Method  (p.  24). 

The  principal  objections  to  the  use  of  cocain  hydrochlorid  as  a 
local  anesthetic  for  hypodermic  use  are  the  sloughing  of  tissue  so  often 
induced,  and  the  liability  to  poisoning.  These  are  important  consid- 
erations and  wiU  be  discussed  separately. 

1.  Sloughing. — It  has  been  demonstrated  quite  conclusively  that 
the  aseptic  injection  of  sterile  isotonic  solutions  of  cocain  hydro- 
chlorid will  not  result  in  sloughing.  Therefore,  sloughing  is  caused 
either  by  septic  infection  due  to  the  injection  or  to  the  irritation  pro- 
duced by  the  disturbed  relations  of  the  cells  from  the  injection  of 
solutions  which  are  not  isotonic  to  the  fluids  in  the  tissues.  It  must 
be  understood  here  that  the  latter  cause  mentioned  would  not  result 
in  sloughing  of  itself,  but  the  irritation  thus  produced,  together  with 
the  poisoning  of  the  protoplasm  of  the  cells  by  the  cocain,  so  lowers 
the  vital  resistance  of  the  affected  tissues  that  infection  is  more  liable 
to  follow  hematogenously  (through  the  blood  stream) ,  or  from  external 
influences,  especially  where  there  has  been  laceration  of  tissue,  as  in 
extraction.  Sloughing,  therefore,  is  due  entirely  to  septic  infection, 
either  directly  or  indirectly  from  the  injection  or  from  external  influ- 
ences. How  to  guard  against  septic  infection  has  been  previously 
considered. 

2.  Poisoning.- — Poisoning  by  cocain  hydrochlorid  is  due  either 
to  the  injection  of  an  overdose  or  to  idiosyncrasy.  As  has  been  else- 
where stated,  individuals  differ  widely  in  their  susceptibiHty  to  co- 
cain. In  the  manner  of  its  action,  which  has  alse  been  mentioned 
cocain  is  a  pecuUar  drug.  Its  action  differs  with  different  individuals, 
and  with  the  same  individual  at  different  times.  There  is  no  way  of 
foretelling  how  the  drug  is  going  to  affect  the  patient  in  a  given  case. 


COCAINE  hydrochloridiim:  135 

For  this  reason  many  physicians  and  dentists  are  afraid  to  use  co- 
cain.  However,  if  we  master  the  technic  of  its  administration  and 
always  know  the  quantity  injected,  there  is  no  necessity  for  fright,  even 
though  toxic  symptoms  develop,  providing,  of  course,  that  an  over- 
dose has  not  been  injected.  It  is  practically  agreed  by  the  best  au- 
thorities that  the  maximum  quantity  of  cocain  hydrochlorid  to  be 
permitted  to  enter  the  circulation  at  one  time  should  not  exceed  one- 
quarter  of  a  grain  (0.016  Gm.). 

A  great  many  of  the  ill-results  attributed  to  cocain  are  due  to  the 
carelessness  with  which  the  drug  is  used  or  to  shock  or  fright  on  the 
part  of  the  patient  for  which  the  drug  is  not  at  all  responsible.  This 
is  equally  true  of  the  hypodermic  use  of  all  local  anesthetics.  Many 
times  patients  collapse  from  shock  or  faint  from  fear  or  dread  of  the 
operation;  and,  when  cocain  was  used  these  results  have  frequently 
been  attributed  to  the  drug,  when,  as  a  matter  of  fact,  the  same  result 
might  have  been  and  often  is  produced  when  no  anesthetic  has  been 
used.  Whenever  cocain  is  used  about  the  mouth  for  any  purpose  we 
should  always  have  the  patient  rinse  the  mouth  to  prevent  swallow- 
ing any  of  the  remedy,  for  the  smallest  quantity  of  cocain  in  the 
stomach  will  often  produce  nausea; 

Solutions  of  cocain  hydrochlorid  should  be  made  at  the  time 
from  soluble  hypodermic  tablets,  or  should  contain  antiseptics  to 
keep  the  solution  sterile.  Phenol  is  an  excellent  agent  to  add  for  this 
purpose,  and  in  from  3^  to  i  per  cent,  it  has  no  perceptible  coagulant 
action  on  the  albumin  of  the  cells.  Two  per  cent,  of  boric  acid  may 
also  be  added.  The  author's  formula  for  hjrpodermic  injection, 
which  is  practically  isotonic,  follows: 

Cocain  Hydrochlorid,  5  gr.  (0.3  Gm.) 

Sodium'Chlorid,  i  gr.  (0.06  Gm.) 

Phenol  (95  per  cent.),  2  min.  (0.13  mil) 

Peppermint  Water,  i  fl.  oz.  (30.0  mils) 

It  is  well  to  add  i  min.  (0.06  mil)  of  a  fresh  1-1,000  solution  of 
adrenahn  chlorid  to  30  min.  (2.0  mils)  of  the  solution  at  the  time 
of  injection.  It  should  be  remembered  that  about  23  min.  (1.5 
mils)  of  this  solution  contain  3^  gr.  (0.016  Gm.)  of  the  alkaloidal 
salt,  the  maximum  quantity  which  may  safely  enter  the  circulation 
at  one  time.  This  does  not  mean  that  only  23  min.  can  be  used 
at  one  injection;  for  a  certain  amount  is  lost  in  exhausting  the 
air  from  the  syringe,  and  a  certain  amount  actually  injected  is  re- 
moved before  it  enters  the  circulation,  due  to  the  subsequent  hemor- 
rhage.    If  the  technic  of  injection  has  been  mastered,  one  barrelful 


136  LOCAL   ANESTHETICS 

of  the  syringe  should  be  amply  sufficient  to  painlessly  extract  all 
of  the  teeth  that  should  be  extracted  at  one  tirne,  when  any  local 
anesthetic  has  been  employed.  Cocain  should  never  be  used  with- 
out having  at  hand  in  a  convenient  and  practical  form  the  several 
antidotes  for  the  drug. 

There  are  many  proprietary  local  anesthetic  solutions  on  the 
market,  and  it  is  safe  to  say  that  cocain  enters  into  most  of  them  as 
the  base  of  the  formula.  In  this  day  of  advanced  dental  therapeutics 
there  is  no  necessity  or  excuse  for  using  any  proprietary  remedy,  the 
composition  of  which  is  unknown,  especially  when  we  are  dealing 
with  so  powerful  a  drug  as  cocain.  The  National  Food  and  Drugs 
Act  makes  it  obligatory  for  manufacturers  to  place  on  the  label 
the  amount  of  cocain  in  their  preparations;  and,  as  previously  men- 
tioned, the  Anti-Narcotic  Law  requires  practitioners  to  keep  a 
record  of  the  amount  of  cocain  ordered  and  used. 

Neurocain. — Neurocain  is  a  name  given  to  billets  of  cocain 
hydrochlorid,  each  containing 3-f  2  gr.  (0.005  Gm.),  without  excipient. 
The  billets  are  3^^  in.  long,  J-^o  in.  in  diameter,  and  very  soluble  in 
water.  Cocain  hydrochlorid  is  put  up  in  this  form  expressly  for 
dentists'  use  in  the  removal  of  the  pulp  by  pressure  anesthesia.  They 
are  convenient  for  this  purpose,  especially  where  it  is  desired  to  dis- 
solve the  local  anesthetic  in  the  serum  of  the  blood  in  cases  of  pulp 
exposure.  Similar  preparations  on  the  market  are  called  cocain 
points. 

Incompatibles. — Cocain  hydrochlorid  is  incompatible  with  alka- 
lies and  alkaline  carbonates  and  all  alkaloidal  reagents.  The  drug 
is  decomposed  by  boiling  water. 

Tropacocain  Hydrochlorid. — Tropacocain  is  an  alkaloid  obtained 
from  the  leaves  of  the  Java  coca  plant.  The  hydrochlorid  occurs 
as  white  needles,  readily  soluble  in  water.  In  its  action  it  resembles 
cocain,  but  is  less  toxic  and  does  not  produce  contraction  of  the 
blood-vessels.  Its  local  anesthetic  property  is  not  sufficiently 
profound  to  merit  emplo3mient  as  such  in  dental  practice. 

Ever  since  cocain  has  been  used  as  a  local  anesthetic  in  dental 
and  general  surgery  numerous  attempts  have  been  made  by  manu- 
facturing chemists  to  prepare,  synthetically,  substitutes  for  the  drug; 
among  which  may  be  mentioned  the  following:  The  eucains,  acoin, 
nirvanin,  stovain,  chloretone,  novocain,  and  neothesin.  Many  of 
these  products  were  short-lived  and  failed  to  fill  the  place  for  which 
they  were  introduced,  viz.,  to  displace  cocain  as  a  local  anesthetic. 
Those  which  proved  to  possess  merit  will  here  be  discussed. 


EUCAINA — ^NOVOCAINiE  HYDROCHLOREDUM  I37 

EUCAINA  (Nonofficial) 

(Eucain;  C:2Hi2N02(CH3)3.) 

Eucain  is  a  synthetic  product  and  was  placed  upon  the  market 
at  first  as  "Alpha-eucain"  and  "Beta-eucain,"  two  closely  allied 
bases,  differentiated  as  eucain  "A"  and  eucain  "B."  The  former 
has  been  withdrawn  from  the  American  market,  while  the  latter  is 
used  quite  extensively  in  dentistry  as  a  local  anesthetic  in  the  form 
of  beta-eucain  hydrochlorid. 

BETA-EUCAINiE  HYDRO  CHLORIDUM  (Nonofficial) 
(Beta-eucain  Hydrochlorid;  Eucain  Hydrochlorid  B; 

Ci2Hi2N02(CH3)3.HCl.) 

Beta-eucain  hydrochlorid  occurs  as  a  white  crystalhne  powder, 
soluble  in  20  to  30  parts  of  water  at  the  ordinary  temperature,  more 
soluble  in  warm  water,  soluble  in  25  to  30  parts  of  alcohol.  The 
solutions  are  neutral  and  can  be  sterilized  by  boihng  without 
change. 

Physiologic  Action  and  Therapeutics. — Eucain  is  a  local  anes- 
thetic, Hke  cocain,  but  weaker  and  devoid  of  the  stimulating  action 
of  the  latter.  It  does  not  dilate  the  pupil,  and  it  differs  from  cocain 
in  that  it  does  not  produce  ischemia  by  the  contraction  of  the 
blood-vessels.  By  some  this  is  claimed  to  be  an  advantage,  as  it 
permits  more  profuse  hemorrhage  after  operating,  and  thus  it  is 
supposed  some  of  the  drug  is  carried  out  of  the  part  and  does  not 
enter  the  circulation.  The  solutions  of  beta-eucain  hydrochlorid 
have  the  one  distinct  advantage  of  being  stable  even  on  prolonged 
boiling.  The  drug  may  be  used  in  almost  all  cases  where  cocain  is 
indicated,  a  2  per  cent,  solution  being  about  the  strength  used 
for  the  painless  extraction  of  teeth. 

Incompatibles. — AlkaHes  and  their  carbonates  and  alkaloidal 
reagents. 

NOVOCAINS  HYDROCHLORIDUM  (Nonofficial) 
(Novocain  Hydrochlorid;  C13H20O2N2.HCI.) 

Novocain  hydrochlorid  is  a  synthetic  product,  and  occurs  in 
colorless  needle-shaped  crystals,  readily  soluble  in  water  (i  part) 
and  less  soluble  in  alcohol  (30  parts).  The  aqueous  solutions  of 
the  salt  are  neutral  and  may  be  boiled  without  decomposition.  The 
dose  depends  upon  the  purpose  for  which  the  drug  is   employed. 


138  LOCAL   ANESTHETICS 

Owing  to  its  feeble  toxicity  it  may  safely  be  used  hypodermically 
up  to  4  gr.  (0.25  Gm.)  in  adults. 

Physiologic  Action  and  Therapeutics. — Novocain  is  claimed  to 
be  far  less  toxic  than  any  of  the  synthetic  substitutes  for  cocain. 
It  is  unirritating,  but  when  injected  beneath  the  skin  or  mucous 
membrane  it  exerts  a  prompt  and  powerful  local  anesthetic  action. 
This  effect,  however,  is  not  long  sustained,  but  may  be  overcome 
by  the  simultaneous  injection  of  the  suprarenal  alkaloid  (adrenalin 
or  suprarenin).  The  drug  may  be  employed  as  a  local  anesthetic 
wherever  cocain  is  indicated,  and  often  to  advantage.  It  is  exten- 
sively employed  for  producing  anesthesia  by  the  conductive  or  "nerve- 
blocking"  method.  This  method  requires  special  study  and 
technic.  Excellent  books  on  the  subject,  to  which  the  reader  is 
referred,  are  those  of  Braun-Shields,  Fischer-Rietmiiller,  Lederer, 
and  Throma.  In  recent  years  many  valuable  articles  have  appeared 
in  dental  literature  by  Prinz,  Blum,  Rietmiiller,  Smith,  and  others. 

Incompatibles. — Novocain  hydrochlorid  is  incompatible  with 
alkalies  and  their  carbonates  and  all  alkaloidal  reagents. 

NEOTHESm^  HYDROCHLORIDUM  (Nonofficial) 
(Neothesin Hydrochlorid;  (CH3)2;N(C2Hii)(C2H5)OCO  (C6H5).HC1.) 

Neothesin  is  a  new  S3nithetic  product.  It  occurs  as  a  white, 
freely  soluble  powder.     Not  administered  internally. 

Physiologic  Action  and  Therapeutics. — This  drug  possesses 
marked  local  anesthetic  properties.  Experiments  have  shown  it 
to  be  equal  in  anesthetizing  power  to  cocain,  one-half  as  toxic  and 
more  rapid  in  its  action.  It  has  the  disadvantage  of  being  irritating 
to  the  tissues  when  administered  hypodermically;  and  is  used  only 
thus  far  in  dentistry  as  a  constituent  of  the  author's  "Desensitizing 
Paste."  Here  its  rapid  anesthetic  action  is  of  great  value  and  its 
irritant  effect  is  of  no  consequence.  AppHed  directly  to  the  exposed 
sensitive  dentinal  fibrillae  it  acts  quickly  thereon  and  temporarily 
paralyzes  the  terminal  ends  thus  exposed.  It  should  be  remembered 
that  the  drug,  Hke  cocain  or  other  local  anesthetics,  thus  applied 
will  not  penetrate  the  softened  dentin.  To  desensitize  the  dentin 
sufficiently  deep  to  permit  of  its  painless  removal,  agents  like  para- 
formaldehyd,  from  which  formaldehyd  gas  is  generated  by  the  heat 
of  the  body,  must  be  used.  Neothesin  will  prevent  the  tooth  from 
aching  while  the  dentin  is  being  desensitized. 


CHLOKBUTANOL — ORTHOFORMUM  I39 

(CHLORBUTANOL  (Nonofficial) 
(Chloretone;  C2Cl3(CH3)20H.) 

Chlorelone  is  a  synthetic  product,  and  occurs  as  a  white  crystal- 
line powder,  with  a  camphoraceous  odor  and  taste.  It  is  sparingly 
soluble  in  water,  but  freely  so  in  alcohol  and  ether.  The  average 
dose  is  10  gr.  (0.6  Gm.). 

Physiologic  Action  and  Therapeutics. — Chloretone,  when  first 
introduced,  was  claimed  to  have  marked,  local,  anesthetic  properties 
and  was  recommended  as  a  substitute  for  cocain.  The  local  anes- 
thetic property,  however,  proved  to  be  rather  feeble.  The  drug 
may  be  classed  as  a  local  anodyne  and  antiseptic,  and  also  acts  when 
taken  internally  as  a  somnifacient.  Its  use  in  dentistry  is  largely 
that  of  an  antiseptic,  and  it  is  added  as  a  preservative  to  solutions 
of  organic  compounds,  such  as  cocain  and  adrenalin. 

ORTHOFORMUM  (Nonofficial) 
(Orthoform;    Methyl    Meta-Amino-Para-Oxybenzoate;    CsHgOsN.) 

Orthoform,  called  also  orthoform-new,  is  a  synthetic  compound, 
and  is  the  methyl  ester  of  meta-amino-para-oxybenzoic  acid.  It 
occurs  in  a  fine,  white,  or  yellowish-white,  crystalline  powder,  neutral 
in  reaction,  odorless  and  tasteless.  It  is  practically  insoluble  in 
water,  but  soluble  in  5  or  6  parts  of  alcohol  and  in  50  parts  of  ether. 
The  average  dose  is  10  gr.  (0.6  Gm.). 

Physiologic  Action  and  Therapeutics. — Orthoform  is  a  local 
anesthetic,  and  in  its  local  action  closely  resembles  cocain,  but  differs 
from  the  latter  in  that  it  does  not  penetrate  the  tissue  on  account 
of  its  insolubility.  It  has  practically  no  action  on  the  unbroken  skin 
or  mucous  membrane  and  produces  no  irritation  except  slight  corro- 
sion about  the  site  to  which  it  is  applied.  The  drug  is  mildly  anti- 
septic and  practically  nontoxic  in  the  usual  doses.  As  an  anodyne 
remedy  for  painful  wounds  or  abraded  surfaces  it  is  an  absolute  specific. 
Mawhinney  suggests  using  equal  parts  of  orthoform  and  euro- 
phen  as  a  dusting  powder  for  burns,  exposed  alveolar  process  after  ex- 
traction, etc.  It  can  be  handled  more  conveniently  in  the  mouth  if 
a  paste  be  made  of  the  mixture  of  orthoform  and  europhen,  using 
liquid  petroleum  as  the  vehicle.  Plain  aseptic  gauze  may  be  satu- 
rated with  this  paste  and  carefully  packed  into  painful  sockets  after 
extraction,  covering  the  exposed  process  and  lacerated  tissue  with 
the  oleaginous  paste.  The  same  packing  is  excellent  after  root 
amputation  and  other  minor  operations  about  the  jaws. 


I40  GENERAL   ANESTHETICS 

Incompatibles. — Orthoform  is  decomposed  by  boiling  water, 
and  incompatible  with  alkalies  and  their  carbonates. 

GENERAL  ANESTHETICS     . 

The  detail  technic  of  the  administration  of  general  anesthetics 
is  a  topic  of  sufficiently  great  importance  as  to  merit  discussion  in  a 
separate  volume  by  specialists  in  this  line  of  work.  Several  excellent 
books  covering  this  phase  of  general  anesthetics  are  on  the  market. 

In  our  discussion  of  the  drugs  grouped  under  this  heading,  the 
author  will  confine  himself  largely  to  materia  medica  proper.  The 
description  of  the  drugs,  their  general  action,  and  the  indication  or 
contraindication  for  their  use  are  subjects  which  should  naturally 
be  considered  in  a  work  of  this  kind.  The  most  important  general 
anesthetics  are: 


Nitroui 

3  Oxid. 

Chloroform. 

Ether. 

Ethyl  Chlorid.* 
Ethyl  Bromid. 

NITROGENH  MONOXIDUM— U.S.P. 

(Nitrogen  Monoxid ;  Nitrous  Oxid ;  Laughing  Gas ;  N2O.) 

Nitrous  oxid  is  a  gas  prepared  by  carefully  heating,  in  a  proper 
apparatus,  ammonium  nitrate.  The  gas  is  collected  over  water  and 
purified  by  running  it  through  a  series  of  wash-bottles.  It  is  colorless, 
odorless,  and  possesses  a  somewhat  sweetish  taste.  By  cold  and 
pressure  it  is  converted  into  a  liquid,  when  it  is  usually  placed  in  iron 
cylinders  and  kept  for  subsequent  use.  When  the  gas  is  administered 
many  times  daily,  as  with  extraction  specialists,  it  is  best  to  manu- 
facture the  gas  fresh  each  morning  and  store  it  in  an  ordinary  gas 
tank  for  this  purpose. 

Physiologic  Action. — Nitrous  oxid  is  the  safest  known  general 
anesthetic.  The  death-rate  from  this  gas,  used  as  an  anesthetic,  is 
less  than  i  :  500,000.  It  is  nonirritating  when  inhaled,  but  pro- 
duces an  increase  of  blood-pressure,  a  sense  of  exhilaration,  ringing 
in  the  ears,  and  lividity  of  the  face;  in  about  one  minute,  if  the  gas  is 
undiluted  with  oxygen,  these  symptoms  are  followed  by  complete 
unconsciousness.  The  muscles  are  not  fully  relaxed,  and  the  conduct 
of  the  patient  while  under  the  influence  of  the  gas  depends  largely 
upon  the  confidence  the  patient  reposes  in  the  anesthetist.  Excite- 
ment, laughing,  cr)dng,  and  a  pugilistic  tendency,  though  all  un- 
consciously, are  often  indulged  in.     It  is  claimed  that  the  anesthesia 


^THER  141 

is  induced  by  a  twofold  action:  the  temporary  displacement  of  oxy- 
gen from  the  blood,  and  the  direct  influence  of  the  gas  on  the  central 
nervous  system.  The  recovery  is  almost  instantaneous  upon  the 
removal  of  the  anesthetic  agent.  When  the  gas  is  mixed  with  air  or 
pure  oxygen  the  excitement  is  apt  to  be  greater  and  the  anesthetic 
effect  more  slowly  produced. 

Therapeutics. — Nitrous  oxid  is  the  ideal  general  anesthetic  for  all 
minor  surgical  operations.  Indeed,  the  gas  mixed  in  proper  propor- 
tions with  pure  oxygen  has  gained  a  reputation  for  operations  in 
major  surgery.  By  this  means  the  patient  may  be  kept  under  the 
influence  of  the  anesthetic  for  hours.  Much  credit  is  due  Teter,  of 
Cleveland,  Bevan,  of  Chicago,  and  others,  for  developing  the  technic 
and  encouraging  the  use  of  prolonged  anesthesia  by  nitrous  oxid 
and  oxygen. 

Many  dental  operations,  like  the  preparation  of  cavities  in  sensi- 
tive teeth,  opening  abscesses,  removing  partially  decalcified  pulp  tissue, 
etc.,  may  be  performed  absolutely  without  pain  under  the  influence  of 
nitrous  oxid  and  oxygen,  carried  to  the  analgesic  stage.  This  method 
was  quite  popular  for  a  few  years  past;  but  it  has  been  practically 
superseded  by  the  author's  Desensitizing  Paste  for  painless  cavity 
preparation,  and  by  conductive  anesthesia  for  this  and  other  dental 
operations. 

iETHER— U.S.P. 

(Ether;  Ethyl  Oxid;  (C2H5)20.) 

Ether  is  made  by  the  action  of  sulphuric  acid  on  ethyl  alcohol.  It 
is  a  transparent,  colorless,  mobile,  and  very  volatile  liquid,  having  a 
characteristic  odor  and  a  burning,  sweetish  taste.  Freely  soluble  in 
alcohol,  chloroform,  oils,  and  in  about  ten  times  its  volume  of  water. 
Ether  is  highly  inflammable;  its  vapor,  when  mixed  with  air  and  ig- 
nited, explodes  violently.  It  should  be  kept  in  well-stoppered  con- 
tainers, preferably  in  tin  cans,  in  a  cool  place,  away  from  Hghts  or 
fire.  The  official  product  contains  about  4  per  cent,  of  alcohol.  The 
average  dose  is  15  min.  (i.o  mil);  for  anesthesia  about  i  fl.  oz.  (30.0 
mils) .  When  ether  is  to  be  used  for  anesthesia  it  is  to  be  dispensed 
only  in  small,  well-closed  containers  and  is  not  to  be  used  for  this 
purpose  if  the  container  has  been  opened  longer  than  twenty-four 
hours.     The  following  preparation  is  of&cial: 

Spiritus  i^theris,  U.S.P.     Dose,  about  i  fl.  dr.  (4.0  mils). 

Physiologic  Action. — When  applied  to  the  skin,  mucous  mem- 
brane, or  tooth-structure,  ether  produces  intense  cold  by  its  rapid 


142  GENERAL   ANESTHETICS 

evaporation,  and  acts  as  a  refrigerant  local  anesthetic.  If  it  is  con- 
fined on  soft  tissue,  great  irritation  results.  When  inhaled  as  a  gen- 
eral anesthetic,  it  irritates  the  mucous  membrane  of  the  respiratory 
tract,  and  at  first  coughing,  choking,  and  a  sense  of  strangulation 
follow.  These  symptoms  are  soon  overcome,  and  complete  loss  of 
consciousness  marks  the  subsequent  stage  of  anesthesia,  when  total 
relaxation  supervenes,  accompanied  by  gentle,  regular  breathing. 
The  drug  is  eHminated  chiefly  by  the  lungs  and  kidneys;  on  the  latter 
organs  it  has  an  irritant  effect,  therefore,  it  should  be  employed  cau- 
tiously as  a  general  anesthetic  in  cases  of  nephritis. 

Therapeutics. — Ether  is  used  largely  as  a  general  anesthetic,  and, 
when  thus  administered  for  dental  purposes,  it  had  better  be  given 
by  an  experienced  anesthetist.  The  ether  spray  is  used  for  ohtnnding 
sensitive  dentin.  This  requires  a  specially  designed  apparatus. 
Good  results  can  also  be  immediately  obtained  by  adjusting  the 
rubber  dam  and  evaporating  the  following  remedy,  applied  to  the 
cavity  on  a  small  pledget  of  cotton:  Cocain,  20  gr.  (1.3  Gm.) ;  chloro- 
form, 2  fl.  dr.  (8.0  mils);  ether,  6  fl.  dr.  (24.0  mils).  Ether  is  a 
valuable  solvent  for  many  substances  insoluble  in  water,  such  as 
resins  and  oils. 

The  spray  may  also  be  used  as  a  local  anesthetic,  preliminary  to 
opening  abscesses,  but  it  is  inferior  to  ethyl  chlorid  for  this  purpose. 

The  compound  spirit  of  ether  (formerly  official  and  commonly 
called  "Hoffmann's  Anodyne")  may  be  mixed  with  an  equal  volume 
of  camphorated  tincture  of  opium  (paregoric)  and  given  in  doses  of  i 
fl.  dr.  (4.0  mils)  to  check  diarrhea  in  hot  weather.  The  compound 
spirit  of  ether  also  is  a  useful  remedy  as  an  antispasmodic  in  children 
with  complications  of  first  dentition. 

Contraindications. — Ether  is  contraindicated  as  a  general  anes- 
thetic in  cases  of  advanced  arteriosclerosis;  tuberculosis  with  a  tend- 
ency to  hemorrhage;  acute  and  chronic  diseases  of  the  kidneys; 
anemia,  when  the  hemoglobin  is  less  than  30  per  cent.;  diabetes, 
especially  when  well  established.  Death  from  ether  usually  results 
from  asphyxia. 

CHLOROFORMUM— U.S.P. 

(Chloroform;  Methyl  Trichlorid;  CHCI3.) 

Chloroform  is  made  for  commercial  purposes  by  the  action  of 
chlorin  on  alcohol.  It  is  a  heavy,  clear,  colorless,  mobile,  and  dif- 
fusible liquid,  having  a  characteristic  odor  and  a  burning,  sweet 
taste.     Soluble  in  about  200  times  its  volume  of  cold  water,  and  in 


CHLOROPOEMUM 


143 


all  proportions  in  alcohol,  ether,  and  oils.  It  is  not  inflammable, 
but  its  heated  vapor  burns,  emitting  a  green  flame  and  noxious 
gases  are  produced.  For  this  reason  care  should  be  taken  not  to 
vaporize  chloroform  in  the  presence  of  a  naked  flame.  It  should 
be  kept  in  amber-colored,  glass-stoppered  bottles,  in  a  dark,  cool 
place.  The  average  dose  is  5  min.  (0.3  mil) ;  for  anesthesia,  about 
}^  fl.  dr.  (15.0  mils).     The  following  preparations  are  official: 

Aqua  Chloroformi,  U.S. P.  Dose,  J-^-2  fl.  oz.  (15.0-60.0  mils). 
Spiritus  Chloroformi,  U.S. P.  Dose,  20-60 min.  (1.3-4.0 mils). 
Lim'mentum  Chloroformi,  U.S. P.  (externally). 

Physiologic  Action.' — When  applied  to  the  skin  or  mucous  mem- 
brane locally,  chloroform  produces  a  sense  of  coldness  by  its  rapid 
evaporation.  If  confined,  it  causes  redness  and  even  vesication. 
When  inhaled  it  produces  general  anesthesia;  the  phenomena  ob- 
served may  be  grouped  under  three  stages,  and  are  described  by 
Stevens^  as  follows:  The  first  stage  is  characterized  by  excitement, 
muscular  rigidity,  and  lessened  sensibility  (analgesia);  the  second 
by  anesthesia  and  muscular  relaxation;  and  the  third  by  stertorous 
breathing,  aboHtion  of  reflexes,  profound  narcosis,  and  absolute 
muscular  relaxation. 

The  drug  is  eliminated  practically  unchanged  through  the  lungs 
and  kidneys,  and  while  it  irritates  the  latter  organs  its  deleterious 
effects  are  less  pronounced,  owing  to  the  smaller  quantity  necessary 
to  induce  profound  anesthesia. 

Therapeutics. — Chloroform  is  a  rapid  and  agreeable  general 
anesthetic.  It  is  far  more  dangerous  than  ether,  the  mortality  being 
five  times  greater,  and  should  never  be  administered  as  a  general 
anesthetic  except  by,  or  in  the  presence  of,  an  experienced  anesthetist. 

With  the  patient  in  the  upright  position,  chloroform  may  be 
carried  to  the  analgesic  stage,  and  sensitive  cavities  prepared,  deciduous 
teeth  extracted,  or  abscesses  lanced.  Most  authorities  agree,  however, 
that  the  drug  should  not  be  inhaled  by  the  patient  unless  in  the  re- 
cumbent position,  and  that  the  analgesic  stage  is  the  most  dangerous. 
It  is  the  safest  practice  to  refrain  from  using  the  drug  in  this  manner, 
except,  perhaps,  in  special  cases. 

Chloroform  is  a  constituent  of  many  hniments  used  for  counter- 
irritation  in  cases  of  pericementitis  and  neuralgia.  The  drug  itself 
may  be  confined,  and  redness  and  even  vesication  follow.  It  has 
long  been  used  as  a  solvent  for  gutta-percha,  forming  a  solution 
known  as  chloropercha,  used  in  filling  root-canals.    Like  ether,  the 

^  Modern  Materia  Medica  and  Therapeutics. 


144  GENERAL    ANESTHETICS 

agent  is  used  also  as  a  solvent  for  many  otherwise  insoluble  substances. 

The  liniment  of  chloroform  has  been  extensively  used  as  a  stimu- 
lating remedy  in  muscular  rheumatism,  sprains,.Sind  bruises. 

Indications  and  Contraindications. — Chloroform,  though  more 
dangerous  than  ether,  is  to  be  preferred  to  the  latter  as  a  general 
anesthetic  in  all  acute  inflammatory  diseases  of  the  bronchi  or  lungs, 
advanced  diseases  of  the  blood-vessels,  acute  and  chronic  diseases  of 
the  kidneys.  In  the  extraction  of  teeth  ether  is  considered  the  safer 
anesthetic ;  chloroform  being  more  apt  to  cause  cardiac  paralysis 
reflexly  by  way  of  the  superior  or  inferior  dental  nerve.  Chloroform 
is  contraindicated  in  all  cardiac  diseases,  and  if  administered  here 
must  be  given  cautiously.  Death  from  chloroform  usually  results 
from  circulatory  failure. 

As  has  been  stated,  the  drug  is  pleasant  to  inhale,  and  many 
individuals  have  the  chloroform  habit. 

^THYLIS  BROMmUM    (Nonofficial) 
(Ethyl  Bromid;  Hydrobromic  Ether;  C2H5Br.) 

Ethyl  bromid  is  made  by  heating  a  mixture  of  ethyl  alcohol, 
sulphuric  acid,  and  potassium  bromid.  When  pure,  it  occurs  as  a 
colorless,  highly  volatile  Hquid,  having  an  odor  resembling  chloro- 
form and  a  sweetish  taste.  It  is  inflammable,  and  on  exposure  to 
air  it  liberates  bromin  and  hydrobromic  acid  and  becomes  unfit  for 
use.  It  should  be  kept  in  dark  amber-colored  bottles,  tightly  stop- 
pered. The  dose  as  a  general  anesthetic  is  from  i-6  drams  (4.0- 
24.0  mils),  depending  upon  the  age  and  condition  of  the  patient. 

Physiologic  Action  and  Therapeutics. — ^As  a  general  anesthetic, 
ethyl  bromid  somewhat  resembles  the  action  of  chloroform.  It 
may  be  used  for  short  operations,  but  has  nothing  to  recommend  its 
employment  over  nitrous  oxid  except  that  it  does  not  require  cumber- 
some apparatus  for  its  administration.  The  anesthesia  is  quickly 
and  pleasantly  induced  and  the  recovery  is  rapid,  but  subsequently 
the  patient  may  have  general  mild  depression.  Pain  is  abolished 
before  consciousness.  The  respiration  is  paralyzed  at  about  the 
same  time  as  the  reflexes,  so  that  the  zone  of  safety  is  very  narrow. 
Tetanic  spasms  have  occurred.  Deaths  caused  by  this  drug  were 
formerly  attributed  to  impurities,  but  several  have  occurred  when  a 
pure  article  was  given.  It  must  be  regarded  as  a  very  dangerous 
agent,  especially  in  inexperienced  hands. 

Those  drugs  not  included  in  this  group,  which  possess  general 


ANTIPYRESTA  145 

analgesic  or  anodyne  properties,   will  -be  considered   under  other 
headings  in  the  following  pages. 

ANTIPYRETICS 

Antipjrretics,  called  also  febrifuges,  are  drugs  which  reduce  the 
body  temperature  when  abnormally  high.     This  group  includes: 

Coal-tar  Derivatives:  Cinchona,  especially  its  alkaloid, 

Antipyrin.  Quinin. 

Acetanilid. 
Phenacetin. 
Pyramidon. 

ANTIPYRINA— U.S.P. 

(Antipyrin;    C6H5(CH3)2C3HN20.) 

Antipyrin  is  a  coal-tar  derivative,  basic  in  character,  obtained  by 
the  condensation  of  phenyl  hydrazin  with  diacetic  ether  and  methyl- 
ization  of  the  product.  It  occurs  as  a  white,  crystalhne  powder  or 
scales,  odorless,  of  a  slightly  bitter  taste,  freely  soluble  in  water, 
alcohol,  and  chloroform.     The  average  dose  is  5  gr.  (0.3  Gm.). 

Physiologic  Action. — Antipyrin  has  no  action  on  the  unbroken 
skin.  It  first  irritates  and  then  blanches  mucous  membranes,  result- 
ing in  an  analgesic  effect.  It  may  be  considered  a  mild  antiseptic, 
and  applied  locally  to  abraded  surfaces  it  contracts  the  blood-vessels 
and  acts  as  a  mild  styptic.  Internally  administered,  it  reduces 
abnormally  high  temperatures,  as  in  fevers,  but  has  practically  no 
action  in  health.  The  drug  here  dilates  the  blood-vessels  and  in- 
creases perspiration,  and  thus  heat  reduction  is  brought  about.  Anti- 
pyrin differs  from  other  aniUn  derivatives  (acetanilid)  in  that  it  has 
no  appreciable  action  upon  the  blood  itself,  and  in  this  respect  it  is 
a  much  safer  analgesic. 

Therapeutics. — Antipyrin  is  a  comparatively  safe  and  useful 
drug  in  all  conditions,  the  treatment  of  which  calls  for  the  relief  of 
pain.  Some  authorities  place  it  next  to  opium  as  a  general  analgesic. 
The  drug  may  be  given  in  powdered  form  or  in  solution  for  the  relief 
of  pain  of  a  neuralgic  character,  and  whenever  it  is  desirable  to  lower 
temperature  in  fever.  As  an  antispasmodic,  it  is  useful  in  the  child- 
hood period  of  tooth-eruption,  in  whooping-cough,  etc.  Here  it  may 
be  taken  in  combination  with  a  bromid.  The  following  may  be 
given  in  teaspoonful  doses,  further  diluted  with  water,  to  a  child 
three  years  old,  varying  the  dose  according  to  the  age:  Antipyrin, 
45  gr-  (3-°  Gm.);  sodium  bromid,  i3-^  dr.  (6.0  Gm.);  glycerin,  3^  fl. 


146  ANTIPYRETICS 

oz.  (15.0  mils);  peppermint  water,  23^  fl.  oz.  (75.0  mils).  In  capil- 
lary oozing  after  operations,  the  drug  may  be  applied  locally 
in  powdered  form,  or  a  20  to  30  per  cent,  solution,  which  is  less 
irritating. 

Incompatibles. — Antipyrin  is  incompatible  with  tincture  of 
iodin,  mercuric  and  mercurous  chlorid,  the  ferric  salts  in  solution, 
phenol,  chloral,  beta-naphthol,  sodium  bicarbonate,  sodium  salicy- 
late, orthoform,  spirit  of  nitrous  ether,  and  the  salts  of  quinin  and 
caffein.  The  wide  range  of  incompatibles  is  due  to  the  basic  prop- 
erties of  the  drug. 

ACETANILIDUM— U.S.P. 

(Acetanilid;  Antifebrin;  C6H5NH.C2H3O.) 

Acetanilid  is  a  coal-tar  product,  derived  from  anilin,  an  atom 
of  hydrogen  in  the  latter  being  replaced  by  the  acetic  acid  radical. 
It  occurs  as  a  white,  shining,  crystalline  powder,  without  odor,  of  a 
faintly  burning  taste ;  sparingly  soluble  in  water,  freely  in  alcohol  and 
chloroform,  and  somewhat  less  so  in  ether.  The  average  dose  is  3  gr. 
(0.2  Gm.).     There  was  formerly  one  official  preparation: 

Pulvis  Acetanilidi  Compositus,  U.S. P.  VIII  (Compound 
Acetanilid  Powder;  Acetanilid,  70  parts;  Caffein,  10  parts; 
Sodium  Bicarbonate,  20  parts).     Dose,  7^^  gr.  (0.5  Gm.). 

Physiologic  Action. — ^Like  antipyrin,  in  moderate  doses  in  health 
acetaniUd  has  no  perceptible  effect.  Internally  administered  in 
fever,  the  drug  produces  marked  fall  of  temperature,  due,  in  all  proba- 
biHty,  to  its  direct  influence  on  the  centers  which  regulate  heat- 
production.  Free  perspiration  frequently  accompanies  the  fall  of 
temperature.  In  large  doses  acetanilid  acts  as  a  cardiac  depressant 
and  induces  blood-changes.  The  blood  assumes  a  chocolate  color, 
due  to  the  production  of  methemoglobin.  It  is,  therefore,  not  as  safe 
an  analgesic  as  antipyrin,  though  exerting  a  greater  influence  over 
the  nerve  centers  which  control  pain.  Applied  locally  to  mucous 
membranes  or  abraded  surfaces,  the  drug  is  nonirritating  and  exerts 
an  analgesic  effect  by  depressing  the  sensory  nerve-endings. 

Poisoning  and  Treatment. — The  symptoms  of  poisoning  by 
acetanilid  are  marked  cyanosis,  feeble  breathing,  pulse  soft,  slow, 
later  rapid  and  weak,  free  perspiration,  pupils  dilated  and  ultimate 
collapse.  In  the  treatment  of  poisoning  the  body  temperature  should 
be  maintained  by  external  heat  and  such  cardiac  and  respiratory 
stimulants  given  as  strychnin  sulphate,  ammonia,  and  atropin  sul- 


ACETPHENExmrisruM  147 

phate.  In  combating  the  cyanosed  condition  inhalations  of  pure 
oxygen  and  artificial  respiration  are  important. 

Therapeutics. — Acetanilid,  judiciously  employed,  is  a  valuable 
drug  for  the  relief  of  pain  in  many  diseased  dental  conditions,  such  as 
acute  abscess,  neuralgia,  headache,  etc.  It  is  always  best  to  combine 
the  drug  with  a  stimulant  to  overcome  the  depressant  effect  of  ace- 
tanilid upon  the  heart.  In  the  formerly  official  powder,  caffein  is 
added  for  this  purpose.  Harlan  suggested  a  formula  wherein  whisky 
was  added  as  the  cardiac  stimulant.  It  is:  Acetanilid,  10  gr.  (0.65 
Gm.) ;  simple  syrup,  }4  A-  oz.  (15.0  mils) ;  whisky,  2  3^  fl.  oz.  (75.0 mils). 
The  compound  powder,  which  can  be  obtained  in  tablets,  is  an  ex- 
cellent form  in  which  to  administer  the  drug. 

The  drug  may  be  cautiously  applied  locally  in  powdered  form  in 
the  treatment  of  wounds,  burns,  ulcers,  or  other  abraded  surfaces,  but 
is  far  inferior,  as  a  local  analgesic,  to  orthoform. 

ACETPHENETIDINTJM— U.S.P. 
'  (Acetphenetidin;  Phenacetin;  C6H4OC2H5.NHC2H3O.) 

Acetphenetidin,  commonly  called  phenacetin,  is  a  coal-tar  prod- 
uct obtained  by  the  action  of  glacial  acetic  acid  on  paraphenetidin 
(an  anilin  derivative),  one  atom  of  hydrogen  in  the  latter  being  re- 
placed by  the  acetic  acid  radical.  It  occurs  as  white,  glistening, 
crystalline  scales  or  fine  powder,  without  odor  or  taste,  sparingly 
soluble  in  water,  but  freely  so  in  alcohol  and  glycerin.  The  average 
dose  is  5  gr.  (0.3  Gm.) . 

Physiologic  Action  and  Therapeutics. — Internally  administered, 
phenacetin  exerts  a  similar  action  to  that  produced  by  antipyrin  and 
acetanihd,  though  all  authorities  claim  that  it  is  far  less  toxic  than 
either  of  these  drugs.  Everything  considered,  it  is  the  most  satis- 
factory of  all  of  the  coal-tar  antipyretics.  Probably  the  only  objec- 
tion that  may  be  offered  to  its  use  is  that  it  is  more  expensive  than 
antipyrin  or  acetanilid,  but  when  its  safety  is  considered  even  this 
possible  objection  is  outweighed.  It  may  be  advantageously  em- 
ployed in  all  cases  where  the  other  coal-tar  analgesics  have  been  men- 
tioned. A  useful  formula  is  the  combination  of  phenacetin  and 
codein  sulphate  in  the  proportion  of  5  gr.  (0.3  Gm.)  of  the  former  to 
^i  gr.  (0.03  Gm.)  of  the  latter  for  an  adult  dose. 

Though  the  actions  of  antipyrin,  acetanilid,  and  phenacetin  are 
similar,  frequently  results  are  obtained  by  the  use  of  one  of  the  drugs 
where  the  others  have  failed. 


148  ANTIPYRETICS 

PYRAMIDON  (Nonoflacial) 

/CO-CN(CH3)2 

C6H5N< 

^N(CH3).C(CH3). 

Pyramidon  is  dimethylaminoantipyrina  and  differs  from  anti- 
pyrin  in  that  a  dimethylamino  group,  N(CH3)2,  has  replaced  a  hydro- 
gen atom  of  the  pyrazolon  nucleus.  It  occurs  in  small,  colorless, 
slightly  alkaline  crystals,  almost  tasteless;  soluble  in  11  parts  of  cold 
water  and  readily  soluble  in  alcohol,  ether  and  benzene.  The 
average  dose  is  5  gr.  (0.3  Gm.),  most  conveniently  given  in  the  form 
of  tablets,  a  single  dose  usually  sufficing  for  twenty-four  hours. 

Physiologic  Action  and  Therapeutics. — Pyramidon  acts  as  an 
antipyretic  and  general  anodyne,  like  antipyrin,  but  is  effective  in 
smaller  doses  and  the  effect  persists  longer,  though  somewhat  slower 
at  the  beginning.  It  is  claimed  to  be  comparatively  free  from  harm- 
ful influences  on  the  blood,  heart,  or  kidneys.  In  all  cases  in  den- 
tistry calling  for  the  relief  of  pain  it  may  be  given.  Like  other 
antipyretics,  it  should  be  cautiously  employed  in  the  treatment  of 
infectious  fevers. 

Incompatibles. — In  general  the  drug  is  incompatible  with  the 
same  agents  as  is  antipyrin.  Oxidizing  agents  (also  acacia)  often 
produce  colored  solutions. 

CINCHONA— U.S.P. 

(YeUow  Peruvian  Bark;  Yellow  Cinchona.) 

Cinchona  is  the  dried  hark  of  Cinchona  calisaya,  Cinchona  ledger- 
iana,  Cinchona  officinalis,  and  several  other  species  of  Cinchona,  tall 
evergreen  trees  indigenous  to  South  America,  and  now  cultivated  in 
Ceylon,  Java,  and  Jamaica.  Red  cinchona  is  also  official.  Cinchona 
Rubra,  U.S. P.,  and  is  the  dried  bark  of  Cinchona  succirubra.  Both 
specimens  should  yield  not  less  than  5  per  cent,  of  total  anhydrous 
cinchona  alkaloids,  of  which  there  are  several;  the  most  important 
are  quinin,  quinidin,  cinchonin  and  cinchonidin.  The  following  prepa- 
rations are  official : 

Fluidextractum  Cinchonae,  U.S. P.  Dose,  }i-i  fl.  dr.  (2.0- 
4.0  mils). 

Tinctura  Cinchonae,  U.S. P.  Dose,  1-2  fl.  dr.  (4.0-8.0  mils). 
Tinctura  Cinchonae  Composita,  U.S. P.  (Huxham's  Tincture; 
Red  Cinchona,  10;  Bitter  Orange  Peel,  8;  Serpentaria,  2). 
Dose,  1-4  fl.  dr.  (4.0-15.0  mils). 


QumiNA  ■  149 

Several  of  the  alkaloids  and  their  salts  are  also  official.     They  are: 

Qiiinina,  U.S. P.     Dose,  i-io  gr.  (0.06-0.65  Gm.). 

Quininse  Sulphas,  U.S. P.     Dose,  1-20  gr.  (0.06-1.3  Gm.). 

Quininae  Bisulphas,  U.S. P. 

Quininse  Dihydrochloridum,  U.S. P. 

Quininae  Hydrochloridum,  U.S. P. 

Quininae  Hydrobromidum,  U.S. P. 

Quininae  Salicylas,  U.  S.  P.     Dose,  i-io  gr.  (0.06-0.65  Gm.). 

Cinchoninae  Sulphas,  U.S. P. 


Dose,  1-15  gr.  (0.06-1.0  Gm.). 


Cinchonidin^  Sulphas,  U.S.P.  /  ^'"'^  ^"^-^  ^'-  ^^'^^'^'^  ^^•)- 

Quininae  Dihydrochloridum,  U.S.P.  Dose,  1-15  gr.  (0.06-1.0  Gm.). 

Quininae  et  Ureae  Hydrochloridum.  Dose,  hypodermic  (one 
dose  daily)  15  gr.  (i.o  Gm.). 

It  will  be  observed  that  there  is  rather  a  wide  range  of  dosage 
given  for  these  alkaloidal  salts  of  quinin.  The  reason  for  this  is  that 
they,  Uke  quinin  itself,  are  given  both  as  a  tonic  and  antimalarial. 
The  dose  as  a  tonic  is  much  smaller  than  for  antimalarial  purposes. 

Inasmuch  as  quinin  is  the  most  important  alkaloid  of  cinchona 
and  represents  largely  its  active  properties,  it  will  be  the  only  con- 
stituent here  described. 

QummA— U.S.P. 

(Quinin.) 

Quinin  occurs  as  a  white,  flaky,  amorphous  or  crystalline  powder, 
odorless,  and  of  an  extremely  bitter  taste.  It  is  practically  insoluble 
in  water,  but  is  readily  soluble  in  acidulated  water,  alcohol,  and  ether. 

Physiologic  Action. — Quinin  acts  differently  upon  different  in- 
dividuals. In  large  doses,  and  with  some  subjects  in  comparatively 
small  doses,  it  causes  a  sense  of  fullness  in  the  head,  ringing  in  the  ears, 
deafness,  headache,  and  sometimes  dimness  of  vision.  This  group 
of  S3nnptoms  is  included  in  the  term  cinchonism.  The  drug  is  ab- 
sorbed chiefly  from  the  stomach,  and  its  action  augments  the  secre- 
tions from  the  salivary  and  gastrointestinal  glands ;  it,  therefore,  may 
be  considered  a  stomachic  and  tonic.  Through  the  kidneys  is  the 
principal  mode  of  elimination.  Butler^  states  that  quinin  has  a 
remarkable  effect  upon  the  constituents  of  the  blood.  The  ameboid 
movements  of  the  white  bfood-corpuscles  are  arrested,  preventing 
them  from  migrating  through  the  capillary  walls  in  inflammation. 
Full  doses  of  the  drug  also  diminish  the  white  blood-corpuscles,  while 
the  red  corpuscles  are  proportionately  increased.  Quinin  diminishes 
the  metabolism  of  the  body  by  lessening  the  oxygen-carrying  power 

^  Text-Book  of  Materia  Medica,  Therapeutics  and  Pharmacology. 


150  HYPNOTICS 

of  the  red  blood-corpuscles.  Though  it  is  doubtful  that  quinin  ever 
directly  caused  the  death  of  a  human  being,  idiosyncrasies  are  fre- 
quently encountered.  Two  or  3  gr.  (0.13-0.2  Gm:)  have  been  known 
to  produce  intense  cinchonism  in  some  individuals,  and  quinin  rashes 
are  not  uncommon.  The  drug  also  acts  as  an  antiseptic  and  it  is 
claimed  to  possess  local  anesthetic  properties.  Quinin  and  urea 
hydrochlorid  is  now  being  used  as  a  local  anesthetic.  This  is  a  com- 
pound of  quinin  hydrochlorid  and  urea  hydrochlorid,  containing 
approximately  60  per  cent,  of  anhydrous  quinin.  When  injected 
hypodermically  or  when  applied  locally  to  mucous  membranes  it 
exerts  an  anesthetic  action  similar  to  that  of  cocain,  which,  however, 
may  be  prolonged  for  several  days. 

Therapeutics. — Quinin  has  been  used  extensively  as  a  domestic 
remedy  for  many  ills,  and  most  individuals  know  how  the  drug  affects 
them.  This  will  govern  the  dentist  in  regard  to  the  dose  to  be 
administered  in  a  given  case.  The  drug  is  a  specific  iox  malarial 
fever,  and  may  be  given  in  cases  of  neuralgias  associated  with  the 
teeth;  especially  is  it  indicated  here  in  malarial  regions  and  in  the 
spring  of  the  year  when  the  cHmate  is  more  or  less  damp.  The 
author  prefers  quinin  bisulphate,  as  it  is  more  soluble.  It  should 
be  given  in  gelatin  capsules  rather  than  in  the  dry,  hard,  pilular 
form,  as  the  latter  may  pass  through  the  stomach  undissolved. 
The  newly  official  quinin  dihydrochlorid  is  also  very  soluble,  and  its 
use  has  been  proposed  where  concentrated  solutions  of  quinin  are 
wanted,  as  for  subcutaneous  injections  and  similar  purposes.  Quinin 
is  a  constituent  of  many  bitter  tonics.  Quinin  sulphate  has  been 
recommended  for  its  tonic  and  antiseptic  properties  as  a  local  appH- 
cation  in  pyorrheal  pockets.  The  bitter  taste  of  the  drug  makes  its 
use  here  almost  prohibitive. 

HYPNOTICS 

H3^notics,  also  called  somnifacients,  are  agents  which  induce 
sleep.     The  chief  hypnotics  are: 

Chloral  Hydrate.  Trional. 

Butyl-chloral  Hydrate.  Paraldehyd. 

Sulphonal.  The  Bromids. 

CHLORALUM  HYDRATUM— U.S.P. 

(Hydrated  Chloral;  Chloral;  C2HCI3O  -|-  H2O.) 

Hydrated  chloral  is  obtained  by  the  union  of  a  molecule  of  water 
with  trichloraldehyd,  commonly  called  chloral,  the  latter  being  pre- 


CHLOEALUM  HYDRATUM  151 

pared  by  the  action  of  chlorin  upon  alcohol,  whence  the  name  chlor-al. 
Chloral  hydrate  is  the  official  preparation  and  the  only  one  used  in 
dentistry  or  medicine.  It  occurs  as  colorless,  transparent  crystals, 
having  an  aromatic,  penetrating  odor,  and  a  bitterish,  caustic  taste; 
freely  soluble  in  water,  alcohol,  ether,  and  chloroform.  It  Hquefies 
when  triturated  with  an  equal  quantity  of  menthol,  thymol,  phenol, 
or  camphor.     The  average  dose  is  8  gr.  (0.5  Gm.). 

Physiologic  Action. — AppHed  locally,  chloral  hydrate  acts  as  an 
antiseptic,  mild  anesthetic  and  vesicant.  Even  when  applied  to  the 
unbroken  skin,  it  produces  redness  and  sometimes  vesication.  Inter- 
nally administered  in  therapeutic  doses,  the  drug  induces  quiet  sleep 
of  a  natural  character.  It  is  irritating  to  the  stomach  and  had  better 
be  given  after  meals.  The  chief  action  of  chloral  hydrate  is  upon  the 
nervous  system,  the  sleep  being  the  result  of  the  direct  influence  of  the 
drug  over  the  cerebral  cells  which  lessens  reflex  activity  by  depress- 
ing the  motor  neurons  of  the  spinal  cord.  The  drug  has  a  depressant 
effect  upon  the  cardiac  and  respiratory  centers,  which  is  an  objection 
to  its  use.  Attempts  to  modify  the  drug  so  as  to  make  it  safer  have 
resulted  in  weakening  its  h3^notic  action.  It  is  the  standard  h.y^- 
notic  of  its  class.     It  is  eUminated  principally  by  the  kidneys. 

Poisoning  and  Treatment. — The  symptoms  of  acute  chloral  poison- 
ing are  sleep,  deepening  into  coma.  The  pulse  is  feeble,  thready,  and 
irregular;  temperature  subnormal;  respiration  slow,  followed  by  rapid 
shallow  breathing,  and  ultimate  collapse.  Death  may  result  from 
either  cardiac  or  respiratory  paralysis.  In  the  treatment  of  poisoning 
the  temperature  should  be  maintained  or  restored  by  artificial  heat — 
warm  blankets,  hot  bottles,  etc.  Cardiac  and  respiratory  stimulants, 
Hke  strychnin,  ammonia,  atropin,  and  digitalis  should  be  employed. 
To  prevent  asphyxia,  inhalations  of  pure  oxygen  and  artificial  respira- 
tion should  be  resorted  to  early. 

Therapeutics. — The  principal  use  of  chloral  hydrate  is  to  induce 
sleep  in  cases  of  insomnia.  It  is  especially  indicated  when  the  sleep- 
lessness results  from  overwork,  excitement,  fear,  or  dread.  It  should 
not  be  given  continuously  on  account  of  the  Hability  to  form  habit. 
As  a  hjrpnotic  for  insomnia  resulting  from  pain,  the  drug  is  far  inferior 
to  opium.  On  account  of  the  powerful  depressant  effect  chloral 
hydrate  exerts  upon  the  motor  neurons  of  the  spinal  cord,  it  is  a 
valuable  drug  in  the  treatment  of  the  various  convulsions  and  spas- 
modic disorders  of  childhood,  such  as  the  complications  of  temporary 
dentition,  whooping-cough,  etc.  Combined  with  potassium  bromid 
it  is  considered  one  of  the  best  sedatives  in  the  treatment  of  the  con- 
vulsions of  tetanus  and  strychnin  poisoning. 


152  HYPNOTICS 

Chloral  camphor,  a  clear,  syrupy  liquid,  can  be  made  by  triturat- 
ing equal  parts  of  chloral  hydrate  and  camphor.  This  remedy  may 
be  used  as  an  anodyne  in  cases  of  pulpitis,  and  in  neuralgia. 

Contraindications. — The  drug  is  contraindicated  in  cases  of 
marked  cardiac  and  respiratory  weakness. 

Incompatibles. — Chloral  hydrate  is  incompatible  with  alkalies 
and  strong  solutions  of  antipyrin. 

Butyl-chloral  Hydrate.' — This  product  is  produced  by  the  action 
of  chlorin  on  acetic  aldehyd,  hydrated  by  the  addition  of  water.  It 
occurs  in  white,  pearly  scales,  having  a  pungent  odor,  and  an  acid, 
disagreeable  taste.  It  is  practically  insoluble  in  water,  but  freely 
soluble  in  alcohol  and  glycerin.  The  average  dose  is  8  gr.  (0.5 
gm.). 

Physiologic  Action  and  Therapeutics. — In  its  action,  butyl-chloral 
hydrate  resembles  chloral  hydrate,  except  that  it  is  less  powerful 
as  a  hypnotic  and  more  analgesic.  Authorities  claim  that  the  fifth 
or  trigeminal  nerve  is  especially  susceptible  to  the  influence  of  butyl- 
chloral  hydrate,  and  the  drug  has  been  extensively  used  in  the  treat- 
ment of  trifacial  neuralgia  and  migraine.  The  drug  is  best  given  in 
the  form  of  capsules  on  account  of  its  disagreeable  taste. 

Incompatibles. — Butyl-chloral  hydrate  is  incompatible  with 
alkahes. 

SULPHONMETHANUM— U.S.P. 

(Sulphonmethane ;  Sulphonal;  (CH3)2C(S02C2H5)2.) 

Sulphonal  is  a  synthetic  product  obtained  by  the  oxidation  of  a 
mixture  of  ethyl  hydrosulphid  and  acetone  (a  Uquid  resembHng  ethyl 
alcohol  in  its  action).  It  occurs  as  a  colorless,  odorless,  and  nearly 
tasteless,  crystalline  powder;  soluble  in  360  parts  of  cold  water,  in  15 
parts  of  boihng  water,  and  in  65  parts  of  cold  or  2  parts  boihng  alco- 
hol. The  drug  is  stable  and  is  not  affected  by  strong  acids  or  alka- 
lies.    The  average  dose  is  12  gr.  (0.75  Gm.). 

Physiologic  Action. — Sulphonal  is  a  pure  h3rpnotic,  its  action  as 
such  being  intensified  by  combining  it  with  morphin  or  codein.  It 
has  no  depressant  effect  upon  the  heart,  but,  like  chloral  hydrate,  it 
acts  chiefly  on  the  nervous  system  by  depressing  the  cerebral  cortex; 
its  influence,  however,  is  less  than  the  latter  drug  and  its  action  much 
slower,  due  to  its  insolubiHty  in  the  gastric  fluids.  The  hypnotic 
effect  of  sulphonal  may  not  be  evidenced  for  several  hours  after  the 
administration  of  the  drug. 

Poisoning  and  Treatment. — The  symptoms  of  acute  sulphonal 
poisoning  are  headache,  vertigo,  marked  cyanosis,  vomiting,  dia,rrhea, 


SULPHONETHYLMETHANTJM — PARALDEHYDUM  1 53 

respiration  shallow,  pulse  feeble,  unconsciousness  and  final  collapse. 
Some  individuals  who  become  habitual  takers  of  this  class  of  drugs 
present  irregular  toxic  symptoms,  consisting  of  sleepiness  and  stu- 
pidity, loss  of  appetite  and  muscular  weakness.  With  some  papu- 
lar eruptions  are  not  uncommon.  The  treatment  of  acute  poisoning  con- 
sists in  the  discontinuance  of  the  drug;  the  administration  of  saHne 
cathartics,  and  cardiac  and  respiratory  stimulants  as  indicated  by  the 
symptoms  present. 

Therapeutics. — Sulphonal  is  used  internally  as  a  hypnotic.  It 
has  no  other  effect,  and  is  never  used  externally.  In  insomnia, 
caused  by  nervous  excitement,  grief,  or  overwork,  it  is  a  useful  hypnotic. 
In  insomnia  due  to  pain,  it  is  practically  worthless,  unless  combined 
with  the  alkaloids  of  opium.  Sulphonal  should  always  be  given  in 
powder  or  capsules  or  hot  whisky.  The  compressed  tablets,  unless 
crushed,  should  be  avoided  on  account  of  the  sparing  solubility  of  the 
drug. 

SULPHONETHYLMETHANUM— U.S.P. 
(Sulphonethylmethan ;  Trional;  C2H5.CH3.C(S02C2H5)2.) 

Trional  is  a  synthetic  product  containing  three  ethyl  radicals, 
where  sulphonal  contains  but  two.  It  occurs  in  colorless,  lustrous, 
odorless,  and  almost  tasteless,  crystalline  scales;  soluble  in  195  parts 
of  cold  water,  and  freely  soluble  in  hot  water,  alcohol  and  ether.  The 
average  dose  is  12  gr.  (0.75  Gm.). 

Physiologic  Action  and  Therapeutics. — Trional  closely  resembles 
sulphonal  in  its  action.  Being  more  readily  soluble,  however,  the 
drug  acts  more  quickly  and  has  a  tendency  to  accumulate  in  the  body. 
It  is,  therefore,  more  poisonous  than  sulphonal.  It  is  best  adminis- 
tered in  a  warm  vehicle,  such  as  milk,  tea,  of  brandy.  The  treatment 
of  poisoning  does  not  differ  from  that  of  sulphonal. 

PARALDEHYDUM— U.S.P. 

(Paraldehyd;  C6H12O3.) 

Paraldehyd  is  a  synthetic  product  obtained  by  treating  aldehyd 
with  dilute  sulphuric  or  nitric  acid.  It  occurs  as  a  colorless  Uquid, 
having  a  strong  ethereal  odor,  and  a  burning,  pungent  taste.  It  is 
soluble  in  8  parts  of  cold  water,  somewhat  less  so  in  hot  water,  and  is 
miscible  in  all  proportions  with  alcohol,  ether,  chloroform,  and  the 
oils.     The  average  dose  is  30  min.  (2.0  mils). 

Physiologic  Action  and  Therapeutics. — Paraldehyd  resembles 
chloral  hydrate  in  its  action  in  that  it  depresses  the  brain  and  spinal 


154  HYPNOTICS 

cord.  It  differs  from  the  latter,  however,  in  that  its  depressant  action 
upon  the  heart  is  not  nearly  so  marked,  though  it  causes  a  noticeable 
fall  in  arterial  pressure.  The  drug  is  used  only  internally  as  a  hyp- 
notic, and  as  such  it  is  safe  and  reliable.  It  has  the  great  disadvan- 
tage of  a  nauseating  taste  which  is  difficult  to  mask,  and  its  disagree- 
able odor  is  imparted  to  the  breath  for  some  time  after  its  administra- 
tion. The  s}Tnptoms  of  poisoning  and  the  treatment  of  the  same  are 
similar  to  chloral  hydrate.  As  a  hypnotic  in  dental  practice,  chloral 
hydrate  is  far  preferable  to  sulphonal,  trional,  or  paraldehyd. 

THE  BROMIDS 

The  bromids  of  certain  metals,  notably  potassium,  sodium,  and 
ammonium,  might  well  be  discussed  under  different  headings;  but 
they  are  true  spinal  cord  depressants,  and  when  administered  produce 
hypnotic  influence;  therefore,  they  will  be  considered  here. 

POTASSn  BROMIDUM— U.SJ>. 

(Potassium  Bromid;  KBr.) 

Potassium  bromid  is  a  salt  which  occurs  in  colorless,  or  white 
cubical  crystals  or  granules,  odorless,  with  a  pungent,  saline  taste; 
soluble  in  about  1.5  parts  of  water  and  in  180  parts  of  alcohol.-  The 
average  dose  is  15  gr.  (i.o  Gm.). 

Physiologic  Action. — The  chief  action  of  potassium  bromid  is  on 
the  nervous  system.  It  depresses  both  the  cerebrum  and  spinal  cord. 
The  drug  is  rapidly  absorbed  from  the  stomach,  having  been  found 
in  the  urine  fifteen  minutes  after  its  ingestion.  Its  elimination  is 
somewhat  slower  than  its  absorption,  and  there  is  a  tendency  for  the 
drug  to  accumulate  in  the  body.  The  continued  use  of  potassium 
bromid  is  followed  by  a  group  of  symptoms,  called  hromism,  chief 
among  which  are  anemia,  fetor  of  the  breath,  gastric  disturbance, 
mental  depression,  failure  of  memory,  aboHtion  of  sexual  appetite, 
and  muscular  weakness.  In  the  treatment  of  acute  poisoning, 
ehminatives  should  be  given  (diuretics  and  cathartics),  the  adminis- 
tration of  the  drug  should  be  withdrawn,  and  other  symptoms  treated 
as  presented.  No  fatal  case  of  poisoning  by  potassium  bromid  is  on 
record. 

Therapeutics. — Perhaps  there  is  no  drug  which  will  control  the 
nervousness  due  solely  to  the  dread  of  the  dental  chair  better  than 
potassium  bromid.  The  drug  is  especially  indicated  in  nervousness 
caused  hy  fear  or  dread.     In  cases  of  highly  nervous  individuals  the 


SODII  BROMmUM — ^AMMONII  BROMIDUM  1 55 

drug  may  be  given  in  lo  gr.  (0.6  gm.)  dose,  after  meals  and  well 
diluted,  one  day  previous  to.  the  time  of  the  dental  operation.  On 
account  of  the  nauseating  taste  the  drug  should  be  dissolved  in  one 
of  the  official  syrups.  The  compound  syrup  of  sarsaparilla  is  an 
excellent  vehicle. 

Potassium  bromid  is  one  of  the  best  drugs  to  control  the  con- 
vulsions of  epilepsy,  and  is  often  used  to  advantage  in  the  complica- 
tions of  temporary  dentition.  The  drug  is  irritating  to  the  stomach, 
and  should  always  be  given  after  meals,  well  diluted.  It  may  be 
combined  with  the  antipyretic  drugs  with  excellent  results. 

Incompatibles. — Potassium  bromid  is  incompatible  with  acids 
and  acid  salts.  Certain  alkaloids  are  precipitated  from  neutral 
solutions  by  the  drug. 

SODH  BROMIDUM— U.S.P. 

(Sodium  Bromid;  NaBr.) 

Sodium  bromid  is  a  salt  which  occurs  in  colorless,  or  white,  cubical 
crystals  or  granules,  odorless,  and  of  a  saline,  bitter  taste;  soluble  in 
1.7  parts  of  water  and  in  12.5  parts  of  alcohol.  The  average  dose  is 
15  gr.  (i.o  Gm.). 

Physiologic  Action  and  Therapeutics. — Sodium  bromid  closely 
resembles  potassium  bromid  in  its  action.  It  is  less  irritant  to  the 
stomach  and  less  depressant,  due  to  the  sodium  ion.  Because  of  this 
fact,  it  may  be  substituted  to  advantage  for  the  potassium  salt  in 
certain  cases  in  which  a  bromid  is  indicated.  It  should  be  given  after 
meals,  well  diluted. 

Incompatibles. — The  same  as  protassium  bromid. 

AMMONH  BROMIDUM— U.S.P. 

(Ammonium  Bromid;  NH4Br.) 

Ammonium  bromid  is  a  salt  which  occurs  in  white  crystals  or 
as  a  yellowish-white  powder,  odorless,  and  having  a  disagreeable  salty 
taste;  soluble  in  1.2  parts  of  water  and  in  12.5  parts  of  alcohol.  The 
average  dose  is  15  gr.  (i.o  Gm.). 

Physiologic  Action  and  Therapeutics. — Ammonium  bromid 
resembles  potassium  bromid  in  its  action.  Like  the  sodium  salt,  it 
is  less  irritant  to  the  stomach  and  less  depressant  to  the  nervous 
system.  It  may  be  substituted  for  potassium  bromid  in  all  cases 
calHng  for  the  administration  of  a  bromid.  It  should  be  given  after 
meals,  well  diluted. 


156  NARCOTICS 

Incompatibles. — The  same  as  potassium  bromid,  also  spirit  of 
nitrous  ether. 

NARCOTICS 

Narcotics  are  agents  which  induce  stupor,  and  are  closely  related 
to  stimulants  in  that  the  first  effect  of  their  action  is  generally  that  of 
an  excitant  and  stimulant  to  the  higher  brain,  to  the  mind,  and  to  all 
of  the  bodily  functions ;  this  stage  of  their  action  is  followed  by  pro- 
found sleep  characterized  by  increasing  stupor,  and,  if  the  dose  has 
been  sufficient,  the  second  stage  is  followed  by  a  third,  that  of  coma 
and  insensibihty  (narcotism)  and  ultimate  death  due  to  paralysis  of 
the  centers  which  govern  respiration  and  other  functions  of  Hfe.  The 
chief  narcotics  are: 

Opium  (and  Alkaloids).  Alcohol. 

Hyoscyamus.  Ether.* 

Scopola.  Chloroform.* 

Cannabis  Indica.  Chloral  Hydrate.* 
Tobacco. 

OPIUM— U.S.P. 

Opium  is  the  concrete  milky  exudation  (Juice)  obtained  by  incising 
the  unripe  capsules  of  Papaver  somniferum,  a  poppy  plant  indigenous 
to  Western  Asia  and  cultivated  in  Egypt,  Persia,  Asia  Minor,  and 
other  countries.  It  appears  in  irregular  cakes  or  lumps,  having  a 
dark  brown  color,  a  gummy  consistence,  a  pecuUar  narcotic  odor,  and 
a  bitter  taste.  With  the  possible  exception  of  cinchona,  opium  con- 
tains more  alkaloids  than  any  other  drug.  The  chief  alkaloids,  in  the 
order  of  their  therapeutic  significance,  are  morphin,  codein,  narcein, 
thebain,  narcotin,  and  papaverin.  To  be  up  to  the  official  standard, 
opium,  in  its  normal,  moist  condition,  should  yield  not  less  than  9.5 
per  cent,  of  anhydrous  morphin.  The  average  dose  is  i  gr.  (0.6  gm.). 
The  official  preparations  are : 

Opii  Pulvis,  U.S. P.  (should  contain  not  less  than  10  nor  more 

than  10.5  per  cent,  of  anhydrous  Morphin).     Dose,  34~2  gr. 

(0.016-0. 13  Gm.). 

Opium  Deodoratum,  U.S. P.  (Denarcotized  Opium,  10  to  10.5 

per  cent,  of  Morphin).     Dose,  3^-2  gr.  (0.03-0.13  Gm.). 

Opium  Granulatum,  U.S. P.  (10  to  10.5  per  cent,  of  Morphin). 

Dose,  J^-2  gr.  (0.03-0.13  Gm.). 

Extractum  Opii,  U.S. P.  (20  per  cent,  of  Morphin).     Dose, 

J^-i  gr.  (0.016-0.65  Gm.). 

Tinctura   Opii,   U.S. P.    (Laudanum;    10   per   cent.).     Dose, 

5-20  min.  (0.3-1.3  mils). 


OPIUM  157 

Tinctura  Opii  Deodorati,  U.S. P.  (10  per  cent.).     Dose,  5-20 

min.  (0.3-1.3  mils). 

Tinctura    Opii    Camphorata,    U.S. P.    (Paregoric;    contains 

Camphor,  Benzoic  Acid,  Oil  of  Anise,  and  Powdered  Opium; 

4  fl.  dr.  (15.0   mUs)  represent   about    i  gr.  (0.065  g^a-)  of 

Opium).     Dose,  }i-4  fl.  dr.  (2.0-15.0  mUs). 

Pulvis    Ipecacuanhae    et    Opii,    U.S. P.     (Dover's    Powder; 

contains  10  per  cent,  of  Powdered  Opium;  10  per  cent,  of 

Powdered  Ipecac;  and  80  per  cent,  of  Sugar  of  Milk).     Dose, 

5-10  gr.  (0.3-0.65  Gm.). 

Mistura  Glycyrrhizae  Composita  (from  Camphorated  Tincture    ' 

of  Opium).     Dose,  2-3  fl.  dr.  (8.0-12.0  mils). 

Morphin  and  codein  are  the  chief  alkaloids  of  opium,  and  they 
represent  the  physiologic  activity  of  the  drug.  Both  are  official. 
Morphin  occurs  in  white,  prismatic,  shining  crystals  or  fine  needles, 
odorless,  of  a  bitter  taste,  and  sparingly  soluble  in  water,  freely  so  in 
alcohol.     The  average  dose  is  }/§  gr,  (0.008  Gm.). 

Codein  occurs  in  white  or  nearly  translucent  prisms,  or  a  crystal- 
line powder,  odorless,  and  having  a  faintly  bitter  taste;  soluble  in 
120  parts  of  water  and  in  2  parts  of  alcohol.  The  average  dose  is 
3^gr.  (0.03  Gm.). 

The  salts  of  morphin  and  codein  are  much  more  soluble  than  the 
alkaloids  themselves,  and  these  are  generally  prescribed.  The  follow- 
ing are  official: 

Morphinae     Hydrochloridum,      U.S.  P.     Dose,     H-}^     gr.    - 

(0.008-0.032  Gm.). 

Morphinae  Sulphas,  U.S. P.     Dose,  }i-}i  gr.   (0.008-0.032 

Gm.). 

Codeinae  Sulphas,   U.S. P.     Dose,   }i-2  gr.  (0.03-0.13  Gm.). 

Codeinae  Phosphas,  U.S. P.     Dose,  3^-2  gr.  (0.03-C.13  Gm.). 

Physiologic  Action. — Opium  is  a  narcotic  inducing  stupor,  and** 
as  a  result  true  analgesic  and  hypnotic  effects  are  produced,  the 
dominant  action  being  due  to  the  morphin  which  it  contains.  The 
drug  acts  principally  upon  the  brain,  which  it  soon  depresses,  causing 
sleep.  When  the  dose  has  been  moderate,  a  stage  of  excitement  or 
exhilaration  generally  precedes  the  narcosis.  In  large  doses  opium 
is  a  powerful  respiratory  depressant,  and  in  fatal  cases  of  poisoning 
death  usually  results  from  paralysis  of  the  respiratory  centers. 

All  of  the  secretions,  except  the  perspiration,  are  diminished  by 
opium ;  the  saHvary  glands  are  especially  affected,  causing  great  dry- 
ness in  the  mouth  and  consequent  thirst;  digestion  is  also  impaired 
and  constipation  results. 

There  is  a  difference  of  opinion  in  regard  to  the  local  action  of 


158  NARCOTICS 

morphin.  Stevens^  states  that  morphin,  applied  locally,  acts  as  a 
direct  depressant  to  the  sensory  nerve  filaments.  Many  pharma- 
cologists claim  that  the  alkaloid  has  little  or  no  local  action,  and  that  to 
produce  its  effect  it  must  enter  the  circulation  and  be  carried  to  the 
brain  where  it  depresses  the  central  nervous  system. 

Opium  is  rapidly  absorbed  and  is  eUminated  chiefly  from  the 
viscera  of  the  stomach  and  intestines  (gastrointestinal  mucous  mem- 
brane) and  very  Httle  by  the  kidneys. 

Conditions  and  Drugs  Modifying  the  Action  of  Opium. — There 
are  certain  symptoms,  diseases,  and  drugs  which  greatly  modify  the 
action  of  opium.  Patients  suffering  from  severe  pain,  as  in  acute 
alveolar  abscess,  neuralgia,  etc.,  or  patients  having  diabetes  can 
frequently  take  with  advantage  doses  which,  under  ordinary  circum- 
stances, would  produce  profound  narcosis.  The  age  and  sex  also 
modify  the  action  of  opium.  Children  are  pecuUarly  susceptible  to 
the  drug  on  account  of  their  sensitive  nervous  mechanism,  and,  there- 
fore, smaller  doses  must  be  given  than  the  age  would  naturally  indi- 
cate. The  action  of  opium  is  more  pronounced  on  women  than  on 
men. 

Patients  rapidly  acquire  a  tolerance  of  the  drug  through  frequent 
repetition  of  the  dose,  so  that  habitues  can  often  take  large  quantities 
without  experiencing  the  usual  effects. 

The  hypnotic  action  of  opium  is  enhanced  by  combining  it  with 
hypnotic  drugs ;  its  anodyne  influence  is  increased  by  belladonna  and 
cocain,  and  its  diaphoretic  effects  by  ipecac. 

Poisoning  and  Treatment. — It  is  the  acute  rather  than  the  chronic 
poisoning  by  opium  with  which  the  dentist  should  be  familiar. 
Unless  the  dose  is  very  large,  the  narcotic  symptoms  are  manifested 
by  three  distinct  stages.  The  first  is  excitement  or  exhilaration,  in 
which  the  imagination  is  stimulated  and  the  feelings  are  exalted. 
This  is  soon  followed  by  the  second  stage  in  which  listlessness  and 
drowsiness  are  the  prominent  symptoms,  the  patient  finally  falling 
into  a  deep  sleep ;  the  pulse  is  slow  and  full,  the  pupils  are  contracted 
to  a  pin-point  size,  the  respirations  are  slow  and  difi&cult,  the  muscles 
are  relaxed,  and  the  face  is  pale.  In  this  stage  it  is  still  possible  to 
arouse  the  patient  by  loud  noises,  shaking,  etc.  From  this  stage, 
unless  proper  treatment  is  given,  the  patient  gradually  passes  into  the 
third,  that  of  absolute  coma  and  insensibility — a  sleep  from  which 
he  never  awakens,  death  finally  resulting  from  paralysis  of  the  respira- 
tory and  other  Hfe-centers. 

The  author  well  remembers  his  first  experience  in  poisoning  a  cat 

^  Modern  Materia  Medica  and  Therapeutics. 


OPIUM  159 

with  opium  in  the  pharmacy  course  of  instruction.  A  moderate  dose 
of  morphin  sulphate  was  h3rpodermically  administered.  In  a  few 
minutes  the  animal  imagined  it  had  caught  a  mouse  and  was  happy 
playing  with  it;  after  a  short  time,  it  became  drowsy  and  fell  asleep — 
here  the  pupils  were  contracted,  respiration  was  slow  and  labored,  and 
the  muscles  completely  relaxed ;  finally,  perhaps  a  half -hour  from  the 
time  the  first  symptoms  were  manifested,  the  cat  passed  into  that 
comatose  state  from  which  it  never  awoke. 

In  the  treatment  of  acute  opium  poisoning,  at  least  three  objects 
are  of  prime  importance:  to  eHminate  the  poison,  maintain  respiration, 
and  prevent  failure  of  the  circulation.  The  first  thing  to  do  is  to 
empty  the  stomach  either  by  means  of  the  stomach-pump  or  stimu- 
lating emetics,  as  zinc  sulphate  or  mustard  flour,  and  evacuate  the 
bowels.  Strong  black  coffee  may  be  given  by  the  mouth  or  bowel; 
it  promotes  wakefulness  and  stimulates  respiration.  Atropin  and 
strychnin  may  also  be  given.  The  best  chemic  antidote  is  potassium 
permanganate;  3-5  gr.  (0.2-0.3  gm.)  of  this  drug  should  be  dissolved 
in  a  glassful  of  water  and  given  at  once,  repeated  in  thirty  minutes, 
if  necessary.  Tannic  acid  has  also  been  recommended  as  a  chemic 
antidote,  but  neither  the  morphin  sulphate  nor  hydrochlorid  is  pre- 
cipitated by  it.  Counterirritants,  slapping,  shouting  in  the  ear,  may 
arouse  the  patient  from  his  lethargy.  Continually  walking  the 
patient  or  anything  to  keep  him  awake  is  indicated.  When  the  third 
stage  (narcotism)  is  approaching,  artificial  respiration  by  Sylvester's 
method  or  by  a  pump  is  imperative. 

Therapeutics. — Opium,  or  its  alkaloids,  have  practically  but  one 
use  in  dental  practice  and  that  is  to  control  or  relieve  pain.  It  is  the 
greatest  analgesic  known  and  may  well  be  remembered  as  the  great 
"pain  killer."  In  allaying  the  severe  pain  of  fractures,  malignant 
growths,  and  acute  inflammations  of  serous  membranes  this  drug  has  no 
rival.  Pain  of  moderate  intensity  may  often  be  allayed  by  the 
ordinary  antipyretic  and  hypnotic  drugs;  when  it  is  severe  and  ex- 
cruciating and  the  cause  cannot  be  at  once  removed,  it  is  a  waste  of 
time  to  experiment  with  other  drugs  when  so  potent  an  agent  as  opium 
is  obtainable.  In  neuralgias  and  other  forms  of  recurrent  pain  opium 
or  morphin  should  be  used  only  after  all  other  measures  have  failed, 
and  then  with  extreme  caution,  on  account  of  the  danger  of  forming 
the  opium  habit.  No  drug  except,  perhaps,  alcohol  is  more  entic- 
ing, nor  its  continued  use  more  liable  to  form  the  drug-habit  than 
opium.  It  is  safest  for  a  dentist  never  to  write  a  prescription  for 
the  drug.  With  a  prescription  the  patient  may  be  reheved  from  the 
pain  for  which  the  remedy  was  prescribed,  but  subsequently  he 


l6o  '       NARCOTICS 

might  get  the  prescription  refilled  on  the  least  provocation,  and  thus 
the  habit  be  innocently  formed.  Dover's  powder  is  a  common  and 
valuable  remedy  in  acute  coryza.  It  is  also  a  most-efficient  diaphoretic, 
and  may  be  used  in  dentistry  to  abort  an  acute  alveolar  abscess.  In 
conditions  where  the  pain  is  not  so  severe,  codein  sulphate  may  be 
advantageously  combined  with  other  hypnotic  drugs,  such  as  phe- 
nacetin,  etc. 

Morphin  has  been  added  to  various  formulas  for  devitalizing  the 
pulps  of  teeth.  But  as  the  drug  has  been  shown  to  possess  Httle  or  no 
local  action,  its  use  here  is  practically  valueless,  cocain  being  far 
preferable  to  control  the  irritating  action  of  the  devitahzing  agent 
(arsenic  trioxid) .  It  should  be  remembered  that  opium  and  its  alka- 
loids come  under  the  Federal  Anti-Narcotic  Law;  and  when  purchased 
or  administered  a  record  must  be  kept. 

Contraindications. — On  account  of  the  pecuHar  susceptibility  of 
children  to  the  drug,  if  avoidable,  opium  should  not  be  given  under 
five  years  of  age.  One  minim  (0.06  mil)  of  tincture  of  opium  (lauda- 
num) has  caused  the  death  of  a  child  one  day  old,  and  a  few  minims  of 
camphorated  tincture  of  opium  (paregoric)  have  proved  fatal  to  an 
infant  nine  months  old.  The  death  of  a  nursing  babe  is  even  reported 
where  the  mother  had  taken  a  medicinal  dose  of  laudanum.  The  drug 
is,  therefore,  contraindicated  in  pregnancy  and  nursing  mothers. 

HYOSCYAMUS— U.S.P. 

(Henbane.) 

Hyoscyamus  is  the  dried  leaves  and  flowering  tops  of  Hyoscyamus 
niger,  a  plant  growing  in  Europe,  Asia,  and  North  America.  The 
specimen  should  be  collected  from  plants  of  the  second  year's  growth, 
and  should  >deld,  when  assayed,  not  less  than  0.065  P^^  cent,  of  alka- 
loids, of  which  there  are  two — hyoscyamin  and  hyoscin.  Both  are 
official  in  the  form  of  the  hydrobromid,  the  former  Hyoscyaminae 
Hydrobromidum,  U.S.P.;  the  latter  Scopolamine  Hydrobromidum ; 
also  known  as  hyoscin  hydrobromid,  obtained  from  various  plants 
of  the  Solanacece.  The  average  dose  of  the  leaves  of  hyoscyamus  is  4 
gi".  (0.25  Gm.).  The  average  dose  of  hyoscyamin  hydrobromid  is  1^00 
gr.  (0.0003  Gm.).  The  average  dose  of  scopolamin  hydrobromid  is 
3^00  gr.  (0.0003  Gm.).  The  following  preparations  of  hyoscyamus 
are  official: 

Tinctura  Hyoscyami,  U.S. P.     Dose,  10-60  min.  (0.6-4.0  mils). 
Fluidextractum  Hyoscyami,  U.S. P.     Dose,  5-15  min.  (0.3- 
i.o  mil). 
Extractum Hyoscyami,  U.S. P.     Dose,  H~3  g^.  (0.03-0.2  Gm.). 


CANNABIS  l6l 

Physiologic  Action. — In  therapeutic  doses  hyoscyamus  resembles 
belladonna  in  its  action;  it  causes  dilatation  of  the  pupils,  checks  the 
salivary  secretions,  produces  dryness  of  the  throat,  and  quickens  the 
pulse  and  respiration.  Its  narcotic  action  upon  the  brain  is  some- 
what more  profound  than  that  of  belladonna.  The  consensus  of 
clinical  experience  seems  to  be,  also,  that  hyoscyamin  and  atropin 
closely  resemble  each  other  in  their  action;  with  scopolamin  (hyoscin) 
the  action  is  quite  different,  this  drug  being  a  distinct  hypnotic  in  that 
it  depresses  rather  than  stimulates  the  respiratory  center. 

Therapeutics. — Neither  hyoscyamus  nor  its  alkaloids  are  exten- 
sively used  in  dentistry;  belladonna  and  atropin  answering  all  of  the 
purposes  for  which  the  former  drugs  could  be  employed.  Scopola- 
min hydrobromid  and  morphin  sulphate  in  combination  have  been 
injected  hypodermically  previous  to  the  administration  of  general 
anesthetics  as  a  means  of  inducing  a  more  tranquil  anesthesia. 
By  this  means  there  is  said  to  be  an  absence  of  mental  excitement, 
bronchial  irritation,  and  vomiting.  In  neuralgia  in  individuals  where 
a  tonic  is  indicated  or  in  malarial  regions,  the  following  remedy 
made  into  12  pills  or  capsules,  one  given  before  meals,  will  prove 
beneficial: 

Quinin  Valerianate,  24  gr.  (1.5  Gm.). 
Extract  of  Hyoscyamus,  4  gr.  (0.25  Gm.), 
Extract  of  Cinchona,  8  gr.  (0.5  Gm.). 

CANNABIS— U.S.P. 
(Cannabis  Indica,  U.S.P.  VIII;  Indian  Hemp.) 

Cannabis  is  the  dried  flowering  tops  of  Cannabis  sativa,  or  of  the 
variety  indica,  a  pistillate  plant  growing  in  the  East  Indies.  It 
contains  a  natural  resin  called  cannabin,  and  the  specimen  of  the 
drug  should  be  collected  while  the  fruits  are  as  yet  undeveloped,  for 
they  then  carry  the  whole  of  their  resin.  The  average  dose  is  2  gr. 
(0.13  gm.).     The  official  preparations  are: 

Tinctura  Cannabis,  U.S.P.     Dose,  5-20  min.  (c.3-1.3  mils). 

Fluidextractum   Cannabis,    U.S.P.     Dose,    2-5   min.    (0.13- 

0.3  mils). 

Extractum   Cannabis,   U.S.P.     Dose,   3^-i   gr.    (0.008-0.065 

Gm.). 

Physiologic  Action. — Internally  administered  in  therapeutic 
doses,  cannabis  acts  as  a  mild  analgesic,  hypnotic,  and  sedative.  At 
first  there  is  a  marked  stimulation  of  cerebral  activities,  the  imagina- 
tion is  quickened  and  the  flow  of  ideas  heightened.     There  is  generally 


1 62  NARCOTICS 

a  dreamy  state  accompanying  these  symptoms,  and  the  sensation 
of  pain  and  touch  are  blunted,  as  the  centers  governing  these  are 
affected.  The  excitement  is  finally  followed  by  sleep  which  may  last 
for  several  hours.  Although  alarming  symptoms  often  follow  large 
doses  of  the  drug,  death  directly  attributable  to  it  has  not  been 
reported. 

Therapeutics. — Cannabis  is  employed  for  its  mild  analgesic 
action  in  certain  forms  of  neuralgia,  especially  migraine  and  headache. 
It  is  extensively  employed  as  a  hypnotic  in  melancholia. 

The  extract  should  be  given  in  pill  or  capsule,  the  tincture  and 
fluid  extract  in  alcoholic  menstruum  on  account  of  the  resinous  con- 
stituent (cannabin)  being  precipitated  by  aqueous  solutions.  The 
drug  is  not  employed  for  many  of  the  disorders  for  which  it  was  for- 
merly used. 

TABACUM     (Nonofficial) 
(Tobacco.) 

Tobacco  is  the  commercial  dried  leaves  of  Nicotiana  tabacum,  an 
annual  plant  indigenous  to  tropical  America,  but  cultivated  in  several 
parts  of  the  world,  especially  in  Virginia  and  Cuba.  It  contains  a 
very  poisonous,  volatile,  oily  Uquid  alkaloid,  called  nicotin.  The 
quantity  of  the  alkaloid  varies  greatly  in  the  different  specimens,  de- 
pending largely  upon  the  climate  and  soil  of  the  various  countries  in 
which  it  is  raised.  Cuba  is  supposed  to  produce  about  the  best 
specimens  of  tobacco. 

Physiologic  Action  and  Therapeutics. — Tobacco  is  a  marked 
depressant  nauseant,  and  produces  emesis  by  irritation  as  well  as  by 
systemic  action.  Its  continued  use  by  smoking  or  chewing  it  to  ex- 
cess produces  granular  inflammation  of  the  mucous  membrane  of 
the  mouth  and  pharynx,  atrophy  of  the  retina,  dyspepsia,  lowered 
sexual  vitahty,  sudden  faints,  nervous  depression,  and  cardiac  irrita- 
bility. Used  by  the  young,  it  hinders  the  development  of  the  brain, 
and  interferes  with  metaboHsm  in  general  (Osier) .  It  is  claimed  to 
produce  cancer  of  the  lips  and  tongue,  blunting  of  the  moral  sense, 
mental  aberration,  and  even  insanity.  The  so-called  "  tobacco  heart," 
induces  many  forms  of  nervous,  painful,  and  oppressed  cardiac 
action,  depending  upon  the  age,  quantity  used,  and  other  conditions. 

Nicotin  is  one  of  the  most  deadly  poisons  known.  The  author 
remembers  poisoning  a  cat  with  this  agent  in  the  pharmacy  school. 
The  animal  at  once  became  greatly  excited,  then  there  was  a  wild 
stare,  a  deep  sigh,  and  sudden  death  within  three  minutes  after  the 


STIMULANTS  1 63 

ingestion  of  the  drug.  The  claim  that  nicotin  enters  the  body  from 
smoking  tobacco  is  without  foundation,  as  the  liquid  alkaloid  is  vola- 
tile and  the  heat  breaks  it  up  into  other  compounds  far  less  poison- 
ous. Chewing  tobacco  is  supposed  by  many  laymen  to  allay  tooth- 
ache. The  claim  is  not  justified  from  the  physiologic  action  of  the 
drug.     Tobacco  is  not  used  therapeutically  in  dentistry. 

STIMULANTS 

Stimulants  are  agents  which  increase  the  activity  of  life  processes 
or  functions.  When  the  term  "stimulant"  is  applied  to  medicinal 
agents  it  is  used  in  various  senses  and  is  generally  accompanied  by 
such  adjectives  as  cardiac,  respiratory,  gastric,  restorative,  etc., 
to  indicate  the  various  organs  and  processes  of  the  body  stimulated 
by  the  administration  or  application  of  the  drug. 

CARDIAC  STIMULANTS 

These  are  agents  which  increase  the  junctional  activity  or  the  effi- 
ciency of  the  heart's  action.     The  chief  cardiac  stimulants  are : 

Nux  Vomica  (Strychnin).  Digitalis. 

Alcohol.  The  Nitrites. 

Ammonia.  Camphor. 
Caffein. 

NUX  VOMICA— U.S.P. 

Niix  vomica  is  the  dried  ripe  seeds  of  Strychnos  nux  vomica,  a  small 
tree  growing  in  the  East  Indies.  The  drug  contains  two  important 
alkaloids — strychnin  and  hrucin,  the  former  being  in  excess  and  fully 
representing  the  action  of  the  crude  drug,  which  should  contain,  when 
assayed,  not  less  than  2.5  per  cent,  of  the  alkaloids.  Brucin  resem- 
bles strychnin  in  its  action,  but  is  much  less  powerful.  The  average 
dose  of  powdered  nux  vomica  is  i  gr.  (0.06  Gm.).  The  following 
preparations  are  official: 

Tinctura  Nucis  Vomicae,  U.S. P.     Dose,  5-20  min.  (0.3-1.3 

mils). 

Fluidextractum  Nucis  Vomicae,  U.S. P.     Dose,   1-5  min. 

(0.06-0.3  niil). 

Extractum  Nucis  Vomicae,  U.S. P.     Dose,  3^-K  gr.  (0.008- 

0.03  Gm.). 

As  has  been  stated,  strychnin  fully  represents  the  action  of  nux 
vomica.     This  alkaloid  is  official. 


164  STIMULANTS 

STRYCHNINA— IJ.S.P. 

It  occurs  as  colorless  crystals  or  a  white  crystalline  powder,  odor- 
less and  having  an  intensely  bitter  taste;  sparingly  soluble  in  water, 
Two  salts  of  strychnin  are  official,  the  sulphate  (Strychnine  Sulphas, 
U.S. P.)  and  the  nitrate  (Strychninee  Nitras,  U.S. P.).  Both  in 
appearance  resemble  the  alkaloid  itself,  but  are  much  more  soluble  in 
water.  The  average  dose  of  strychnin  or  of  either  of  its  salts  is 
^'io  gr.  (0.0015  Gm.). 

Strychnin  is  a  constituent  of  the  following  preparations: 

Glycerite  of  the  Phosphates  of  Iron,  Quinin,  and  Strychnin, 

N.F. 

Syrup  of  the  Phosphates  of  Iron,  Quinin,  and  Strychnin,  N.F. 

Compound  Syrup  of  Hypophosphites,  N.F, 

Compound  Laxative  Pills,  N.F. 

EUxir  Iron,  Quinin,  and  Strychnin,  N.F. 

Physiologic  Action. — Strychnin  is  a  true  cardiac  stimulant,  the 
pulse  becoming  stronger  and  more  rapid  under  its  influence  as  a  result 
of  its  action  upon  the  heart  and  vasomotor  center.  The  drug  also 
acts  as  a  powerful  respiratory  stimulant,  the  movements  of  respira- 
tion becoming  deepened  and  quickened.  The  chief  action  ol  strychnin 
is  upon  the  nervous  system.  Here  it  acts  as  a  powerful  stimulant 
to  the  spinal  cord,  especially  the  centers  governing  the  move- 
ments of  the  body.  The  most  marked  effect  of  the  drug,  in  toxic 
doses,  is  increased  reflex  irritabiHty  of  the  spinal  cord,  which  is  shown 
most  conspicuously  by  the  production  of  muscular  rigidity.  Nux 
vomica  or  strychnin,  in  small  doses,  strengthens  the  muscular  move- 
ments of  the  stomach  and  increases  the  flow  of  gastric  secretions. 
It  therefore  acts  as  a  stomachic.  The  drug  is  eliminated  principally 
through  the  kidneys. 

Poisoning  and  Treatment. — If  the  dose  of  strychnin  is  within 
therapeutic  limits,  yet  sufficient  to  produce  shght  toxic  effects,  the 
first  symptom  is  hkely  to  be  a  feeHng  of  uneasiness  with  heightened 
reflex  irritability,  and  this  may  be  followed  by  muscular  twitching 
in  some  part  of  the  body.  With  larger  doses,  spinal  convulsions 
result  from  the  slightest  external  irritation,  causing  the  patient  to  rest 
on  his  head  and  feet  (opisthotonos) ;  the  flexor  muscles  are  overcome 
by  the  extensors,  and  the  feet  are  curved  inward.  The  convulsions 
for  the  most  part  are  intermittent;  during  the  intermission  there  is 
complete  muscular  relaxation.     During  the  attack  the  contraction  of 


STRYCHNINA  165 

the  facial  muscles  causes  the  patient  to  grin  in  a  ghastly  manner,  but 
the  muscles  of  the  jaws  are  unaffected  until  toward  the  last.  This 
latter  diagnostic  sign  should  be  remembered,  as  strychnin  poisoning 
may  become  confused  with  tetanus  on  account  of  the  rigidity  of  the 
muscles  during  the  convulsive  attacks.  In  tetanus  the  muscles  of  the 
jaw  are  very  early  implicated.  Other  diagnostic  marks  of  tetanus, 
as  contrasted  with  it,  are  slower  development  of  the  symptoms  and 
the  continuous  muscular  rigidity.  There  is  never  complete  muscu- 
lar relaxation  even  in  the  intermission  of  the  spasms  as  there  is  in 
strychnin  poisoning. 

The  number  of  convulsive  seizures  varies  in  different  instances, 
but  generally  three  or  four  are  fatal;  the  patient  succumbing  to 
asphyxia  and  exhaustion.  In  the  treatment  of  strychnin  poisoning, 
if  the  patient  is  seen  early  enough,  emetics,  particularly  apomorphin 
hydrochlorid  (Ko  gr.-o.oo6  Gm.)  hypodermically,  should  be  given, 
followed  by  washing  out  the  stomach.  If  violent  convulsions  already 
are  present,  evacuation  of  the  stomach,  as  a  rule,  is  contraindicated, 
as  either  emetics  or  the  stomach-pump  would  provoke  further  attacks. 
Inhalations  of  chloroform  or  amyl  nitrite  will  control  the  spasms. 
As  a  chemic  antidote  tannic  acid  in  solution  may  be  administered. 
Probably  the  best  physiologic  antidotes  are  potassium  bromid  (1-2 
dr. — 4.0-8.0  Gm.)  and  chloral  hydrate  (20  gr.-i.3  Gm.);  when  the 
patient  is  unable  to  swallow,  the  latter  drug  (i  dr.-4.o  Gm.)  may  be 
given  in  an  enema  (per  rectum) .  These  agents  depress  the  nerve 
centers  stimulated  by  the  strychnin.  Since  the  sHghtest  external 
stimulus  will  provoke  convulsions,  the  patient  should  be  disturbed 
as  little  as  possible. 

Therapeutics. — Nux  vomica  or  strychnin  is  used  chiefly  as  a 
cardiac  stimulant,  a  respiratory  stimulant,  a  motorexcitant,  and  a 
stomachic.  Strychnin  sulphate,  in  soluble  tablet  form  of  proper 
therapeutic  dose  {yio  gr.-0.0015  Gm.),  should  be  in  every  dental 
office.  Being  both  a  cardiac  and  respiratory  stimulant  it  makes  a 
valuable  remedy  in  cases  of  poisoning  by  drugs  which  depress  the 
cardiac  and  respiratory  center.  In  poisoning  by  cocain,  opium, 
chloral  hydrate,  aconite,  ether,  chloroform,  or  ethyl  chlorid,  it  should 
be  given  hypodermically  in  full  doses  and  repeated,  if  necessary,  in 
fifteen  minutes.  In  neuralgia  due  to  an  atonic  condition,  strychnin 
is  indicated.  Here  it  may  be  given  in  either  the  eHxir,  syrup,  or 
glycerite  of  the  phosphates  of  iron,  quinin,  and  strychnin. 

Xncompatibles.' — Strychnin  is  incompatible  with  tannic  acid, 
alkalies,  and  the  salts  of  the  halogen  elements  (CI,  I,  and  Br.). 


1 66  STIMULANTS 

ALCOHOL— U.S.P. 

(Ethyl  Alcohol;  C2H5OH.). 

Etiiyl  alcohol  is  obtained  by  the  distillation  of  fermented  sac- 
characeous  substances.  To  be  up  to  the  official  standard  it  must  con- 
tain 92.3  per  cent,  by  weight  or  94.9  per  cent,  by  volume  at  i5.56°C. 
of  absolute  ethyl  alcohol.  It  vnR  be  observed  that  the  tempera- 
ture at  which  alcohol  is  measured  is  not  the  standard  temperature 
(25°C.)  of  the  U.S.P.  IX.  Exception  was  made  in  the  temperature 
for  alcohol  in  order  to  correspond  with  the  Government  regulation. 
It  occurs  as  a  colorless,  transparent,  mobile,  and  volatile  liquid,  hav- 
ing a  pungent  odor,  and  a  burning  taste;  miscible  with  water,  ether, 
and  chloroform  in  all  proportions.  It  is  inflammable  and  burns  with 
a  bluish,  nonluminous  flame. 

The  following  preparations  are  official: 

Alcohol  Dehydratum,  U.S.P.,  Alcohol  Absolutum,  U.S.P. 
VIII  (99  per  cent.  Alcohol). 

Alcohol  Dilutum,  U.S.P.  (41  to  42  per  cent,  by  weight  or  48.4 
to  49.5  per  cent,  by  volume,  at  i5.56°C.  of  Absolute  Alcohol). 

The  following  nonofficial  preparations  contain  alcohol: 

Spiritus  Frumenti,  U.S.P.  VIII  (Whisky;  37  to  47.5  per  cent. 
Alcohol,  distilled  from  fermented  grain). 
Spiritus  Vini  Gallici,  U.S.P.  VIII  (Brandy;  39  to  47  per  cent. 
Alcohol,  distilled  from  fermented  grapes). 
Spiritus  luniperi   Compositus,   U.S.P.   VLll    (equivalent  to 
Gin;  about  60  per  cent.  Alcohol). 

Vinum  Album,  U.S.P.  VIII  (White  Wine;  7  to  12  per  cent. 
Alcohol). 

Vinum  Rubrum,  U.S.P.  \TII  (Red  Wine;  7  to  12  per  cent. 
Alcohol). 

Rectified  Spirit  (85  per  cent,  by  weight  of  Absolute  Alcohol). 
Proof  Spirit  (49  per  cent,  by  weight  of  Absolute  Alcohol, 
Volatile  Oil,  and  other  foreign  material). 
Gin  (42  per  cent,  by  weight  of  Absolute  Alcohol,  distilled  in 
Holland  from  rye  or  barley,  and  flavored  with  juniper  berries 
or  hops). 

IMalted  Liquors  (Beer,  Ale,  and  Porter)  are  prepared  by  fer- 
menting malted  grain  with  hops  and  adding  other  bitters. 
Beer  contains  2  to  3  per  cent,  of  Alcohol;  ale  and  porter,  from 
4  to  6  per  cent.,  besides  carbonic  and  lactic  acids,  malt  extract, 
various  aromatics,  and  certain  salts  of  sodium  and  potassium. 

The  formerly  official  wines  are  made   by  fermentation  of  pure 
grape  juice. 


ALCOHOL  167 

Physiologic  Action. — There  is  much  diversity  of  opinion  regarding 
the  physiologic  action  and  uses  of  alcohol.  Applied  to  the  skin,  it 
extracts  water  from  the  tissues  and  acts  as  a  detergent  and  antiseptic. 
On  the  mucous  membrane  it  extracts  water  with  greater  rapidity, 
coagulates  albumin,  and  causes  a  whitened  and  corrugated  surface. 
The  gastric  functions,  as  well  as  the  flow  of  saHva,  are  reflexly  stimu- 
lated by  its  local  action  in  the  mouth. 

Internally  administered,  alcohol  reflexly  and  rapidly  stimulates 
the  heart  before  absorption  can  take  place,  the  effect  upon  the  circu- 
lation persisting  after  the  absorption  of  the  drug.  It  depresses  the 
vasoconstrictors;  thus  arterial  tension  is  raised,  though  the  arterioles 
are  dilated.  Toxic  doses  depress  the  heart's  action,  and  still  further 
dilate  the  peripheral  blood-vessels.  This  action  of  alcohol,  in  causing 
the  heart  to  beat  stronger  and  faster,  at  the  same  time  dilating  the 
blood-vessels — especially  those  of  the  peripheries — renders  the  drug 
one  of  the  most  valuable  diffusible  stimulants  (Butler).  The  domi- 
nant action  of  alcohol  is  on  the  nervous  system.  It  first  stimulates 
and  then  paralyzes  all  parts  of  the  nervous  system. 

Poisoning  and  Treatment. — The  poisonous  action  of  alcohol  may 
be  discussed  as  acute  and  chronic  alcoholism. 

Acute  Intoxication.^ — The  ingestion  of  large  quantities  of  alcohol 
produces  certain  characteristic  symptoms:  Flushing  of  the  face,  men- 
tal excitement,  a  quickened  pulse  and  respiration ;  in  a  short  time  the 
speech  becomes  incoherent,  the  pupils  are  dilated,  then  follows 
dehrium,  loss  of  coordination,  subnormal  temperature,  vomiting, 
loss  of  abiHty  to  control  the  acts  of  toilet,  and,  finally,  stupor  and 
coma.  If  the  dose  has  not  been  too  large,  recovery  follows  in  a  day 
or  two. 

Stevens^  emphasizes  the  care  to  be  taken  in  order  to  distinguish 
acute  alcohoHsm  from  uremia,  opium  poisoning,  and  apoplexy.  The 
urinous  odor  of  the  breath,  the  small  pupils,  and  the  presence  of 
albumin  in  the  urine  will  serve  to  distinguish  uremia.  The  small 
pupils,  slow  and  labored  respiration,,  and  slow  and  fuU  pulse  will  point 
to  opium  poisoning.  The  unequal  pupils,  hemiplegia,  and  high  tem- 
perature will  indicate  apoplexy.  In  the  treatment  of  acute  alcoholism 
the  stomach  should  be  emptied  of  all  unabsorbed  alcohol  by  the 
stomach-pump,  and  a  stimulating  emetic  (mustard  flour),  or  the  hy- 
podermic injection  of  apomorphin  (ifo  gr.-o.oo6  Gm.)  is  indicated. 
Cautious  inhalations  of  ammonia  should  be  given,  together  with  the 
internal  administration  of  black  coffee.  The  patient  should  be  made 
to  perspire  freely  by  the  appHcation  of  external  heat  (warm  blankets, 

'  Modern  Materia  Medica  and  Therapeutics. 


1 68  STIMULANTS 

etc.),  and  if  there  is  danger  of  collapse,  strychnin  sulphate  (>^o  gr- 
0.002  Gm.)  should  be  hypodermically  administered  and  artificial 
respiration  practised. 

Chronic  alcoholism  is  generally  the  result  of  the  continuous  and 
excessive  use  of  alcohol,  and  is  characterized  by  disturbed  sleep,  fine 
tremor,  mental  impairment,  gastric  irritation,  injection  of  the  eyes, ' 
and  redness  of  the  nose  and  cheeks  from  permanent  dilatation  of 
the  capillaries.  A  frequent  compUcation  of  chronic  alcoholism  is 
delirium  tremens.  This  condition  is  manifested  by  great  mental 
excitement,  insomnia,  incoherent  speech,  tremors,  and  terrifying 
hallucinations  of  sight  and  hearing.  In  favorable  cases  recovery 
follows  in  a  few  days,  but  frequently  symptoms  of  typhoid  and 
pneumonia  develop,  and  the  attack  ends  in  death.  In  the  treatment 
oj  delirium  tremens  the  main  indications,  according  to  Butler,^  are: 

1.  Elimination  by  diaphoresis,  catharsis,  diuresis,  warm  baths, 
etc. 

2.  Support. — Some  alcohol  may  be  necessary.  Easily  digested 
food.     Enema ta,  if  necessary. 

3.  Quiet. — Hypnotics:  opium,  chloral  hydrate,  the  bromids. 

In  the  treatment  of  chronic  alcoholism  it  is  necessary  to  consider 
the  character  of  the  individual  affected.  Butler  states  that  a  thought- 
ful and  extended  experience  with  dipsomaniacs  will  convince  most 
observers  that  the  vast  majority  of  them  suffer  from  a  disease  possess- 
ing usually  a  distinct  and  traceable  etiology,  and  resulting  from  either 
an  inherited  or  acquired  neurosis.  It  is  a  condition  akin  to  epilepsy; 
the  treatment,  therefore,  turns  on  the  discovery  of  the  conditions 
preHminary  to  the  drinking  period  and  the  determination  whether 
this  can  be  prevented  by  dietetic  and  therapeutic  measures,  as  is  done 
in  cases  of  epilepsy. 

The  medicinal  agents  employed  are  strychnin,  atropin,  small  doses 
of  such  alteratives  as  arsenic,  potassium  iodid,  and  mercury,  while 
phosphorus  and  other  restoratives  and  tonics  will  prove  efl&cacious. 

Therapeutics. — Alcohol  is  extensively  used  locally  in  dentistry 
as  a  dehydrater,  detergent,  and  antiseptic.  Its  action  upon  bacteria 
is  no  doubt  due  to  its  power  of  abstracting  water  and  of  coagulating 
albumin.  According  to  the  experiments  of  pharmacologists,  the 
most  effective  dilutions  of  alcohol  against  the  strongly  resisting 
(nonsporing)  bacteria,  such  as  the  pus  organisms,  are  those  containing 
from  60  to  70  per  cent,  by  volume.  The  author  suggests  70  per  cent, 
alcohol  to  which  i  gr.  (0.064  gm.)  of  thymol  to  the  fl.  oz.  (.30.0  mils) 
is  added.     This  is  called  modified  alcohol,  and  is  useful  for  sterilizing 

'  Text-Book  of  Materia  Medica,  Therapeutics  and  Pharmacology. 


AMMONIA  169 

the  teeth  included  in  the  rubber  dam  for  aseptic  root-canal  work,  and 
other  aseptic  operations  involving  the  mucous  membrane. 

For  spraying  the  mouth  previous  to  performing  any  dental  oper- 
ation, the  author  is  very  partial  to  cinnamon  water  to  which  from 
2-5  per  cent,  of  alcohol  has  been  added.  It  should  be  remembered 
that  alcohol  is  less  valuable  as  a  disinfectant  than  as  an  antiseptic  and 
as  a  vehicle  for  stronger  agents  of  this  class;  therefore,  from  10  to  25 
per  cent,  alcohol  makes  an  excellent  addition  to  aqueous  antiseptic 
solutions.  Absolute  alcohol  is  frequently  added  to  tooth-pastes  for 
its  antiseptic  and  solvent  power.  The  drug  is  used  as  a  styptic  to 
check  capillary  oozing,  and  a  very  efficient  means  of  reducing  tempera- 
ture in  fever  is  to  bathe  the  skin  with  alcohol;  the  method  is  also  em- 
ployed to  check  excessive  sweating.  Alcohol  is  a  positive  antidote  for 
phenol,  and  whenever  the  latter  agent  is  being  used  about  the  mouth, 
it  should  be  in  a  convenient  place  to  neutralize  the  caustic  action  of 
phenol,  should  the  latter  accidentally  get  on  the  soft  tissues  of  the 
mouth.  Alcohol  is  employed  internally  as  a  diffusible  circulatory 
stimulant,  a  stomachic,  a  food,  and  a  chemic  antidote  for  phenol.  In 
all  forms  of  sudden  heart-failure,  as  in  syncope,  shock,  snake-bite,  etc., 
it  is  an  invaluable  stimulant.  Whisky  or  brandy  should  be  in  every 
dental  office  to  be  used  as  a  cardiac  stimulant  in  cases  of  cocain  poison- 
ing or  other  conditions  which  depress  the  heart. 

AMMONIA 

(NH3.) 

Ammonia  is  obtained  as  a  by-product  in  the  manufacture  of  coal- 
gas.  It  occurs  as  a  colorless  gas,  having  a  very  penetrating  odor  and 
an  acrid  taste.  It  is  chemically  soluble  in  water,  and  in  chemistry 
it  is  considered  a  h)^othetical  metal,  as  it  acts  like  a  base  in  uniting 
with  acids  to  form  salts.    'The  following  preparations  are  official: 

Aqua  Ammonise  Fortior,  U.S. P.  (Stronger  Ammonia  Water; 

28  per  cent,  by  weight  of  the  Gas). 

Aqua  Ammoniae,  U.S. P.  (Ammonia  Water;  10  per  cent,  by 

weight  of  the  Gas). 

Spiritus  Ammoniae  Aromaticus,  U.S. P.  (Aromatic  Spirit  of 

Ammonia;   contains  Ammonium   Carbonate,   34;  Ammonia 

Water,  go;  Oil  of  Myristica,   i;  Oil  of  Lemon,   10;  Oil  of 

Lavender  Flowers,  i;  Alcohol,  700;  Water  to  make  1,000). 

Dose,  3^  to  I  fl.  dr.  (1.0-4.0  mils). 

Linimentum  Ammoniae,  U.S. P.     Externally. 

Physiologic  Action. — Ammonia  has  a  decidedly  irritant  local 
action,  and  in  concentrated  solution  it  speedily  produces  vesication. 


lyo  STDTCLAXTS 

The  drug  has  the  decided  advantage  of  being  a  gas  which  permits  of 
inhalation,  and  its  irritant  action  upon  the  mucous  membrane  of  the 
respiratory  passages  reflexly  stimulates  the  cardiac  and  respiratory 
centers;  both  the  strength  and  rapidity  of  the  pulse  and  the  depth  and 
rapidity  of  the  respirations  are  markedly  increased.  Given  in  weak 
solutions,  the  drug  stimulates  the  flow  of  gastric  juice,  its  action 
here  resembhng  that  of  other  alkahe  s.  The  gas  acts  upon  the  nen/ous 
system  by  stimulating  the  motor  centers  of  the  spinal  cord,  and  thus 
reflex  acti^-ity  is  increased. 

Poisoning  and  Treatment. — In  toxic  doses  preparations  of  am- 
monia 'are  powerful  corrosive  poisons.  The  characteristic  symptoms 
are  severe  burning  pain  in  the  fauces,  esophagus,  and  stomach,  with 
intense  gastroenteritis.  The  \'iolent  irritation  of  the  throat  some- 
times causes  edema  of  the  larynx,  resulting  in  almost  immediate  death 
from  asphyxia.  In  the  treatment  of  ammonia  poisoning  the  drug 
should  be  neutraHzed  by  some  weak  acid,  hke  vinegar.  This  should 
be  followed  by  demulcent  drinks,  opium  being  indicated  for  the  relief 
of  pain. 

Therapeutics. — The  chief  use  of  ammonia  in  dental  therapeutics 
is  as  a  cardiac  and  respiratory  stimulant.  The  drug  acts  quickly,  and 
is  an  invaluable  remedy  in  syncope,  collapse,  and  other  forms  of  sudden 
heart  failure.  When  it  is  desired  to  give  the  drug  by  inhalation,  as  can 
easily  be  done  on  account  of  the  volatiHty  of  the  gas  from  its  solutions, 
it  is  best  to  select  ammonia  water  as  the  preparation  to  use.  For 
internal  administration  the  aromatic  spirit  of  ammonia  should  be 
selected  and  given  well  diluted  Ammonia  water  in  a  specially  pre- 
pared ampule,  called  ''aspirol,"  and  aromatic  spirit  of  ammonia  in 
30  min.  (2.0  mils)  ampules  are  now  on  the  market.  These  are  con- 
venient forms  in  which  to  keep  the  drug  and  should  be  in  every  dental 
office. 

The  liniment  of  ammonia  is  a  popular  counterirritant  remedy  in 
chronic  rheumatism,  joint  afections,  and  chilblains. 

Incompatibles. — Ammonia  is  incompatible  mth  all  acids,  chlo- 
ral hydrate,  and  alkaloids.  With  ferric  salts  it  forms  ferric  hy- 
droxid,  which  is  an  antidote  for  arsenic.  With  formaldehyd  it  forms 
urotropin. 

AMMONH  CARBONAS— U.S.P. 

(Ammonium  Carbonate;  XH4HC03.NH4XH2C02.) 

The  official  ammonium  carbonate  is  really  a  mixture  of  ammo- 
nium acid  carbonate  and  ammonium  carbamate.     It  occurs  in  white, 


CAFFEINA  171 

internally  translucent,  crystalline  masses,  having  an  extremely  pun- 
gent odor,  and  an  acrid  taste;  soluble  in  4  parts  of  water.  The  aver- 
age dose  is  5  gr.  (0.3  Gm.). 

Physiologic  Action  and  Therapeutics.- — This  drug  is  a  cardiac  and 
respiratory  stimulant,  due  to  the  ammonia  gas  which  is  constantly 
liberated.  It  is  also  a  stimulating  expectorant.  It  enters  into  the 
composition  of  aromatic  spirit  of  ammonia,  which  preparation  is  ex- 
tensively used  in  dental  therapeutics. 

CAFFEINA— U.S.P. 
(Caffein;   C8H10N4O2.H2O.) 

Caffein  is  an  alkaloid  obtained  from  the  leaves  of  Thea  sinensis 
(tea),  or  from  the  seeds  of  Cofea  arahica  (coffee).  It  occurs  in  fine, 
colorless,  silky  crystals,  without  odor,  and  having  a  bitter  taste; 
soluble  in  about  46  parts  of  cold  water.  The  average  dose  is  2}^ 
gr.  (0.15  gm.).     The  following  preparations  are  official: 

Caflfeina  Citrata,   U.S.P.    (Caffein   Citrate).     Dose,    2-5    gr. 

(0.13-0.3  Gm.). 

Caffeina  Citrata  Effervescens,  U.S.P.     Dose,  1-2  dr.  (4.0-8.0 

Gm.). 

Caffeinae  Sodio-Benzoas,  U.S.P.     Dose,  by  mouth,  5  gr.  (0.3 

Gm.),  hypodermic,  3  gr.  (0.2  Gm.). 

Physiologic  Action. — Caffein  is  a  powerful  cardiac  and  respiratory 
stimulant.  Its  action  upon  the  circulatory  system  results  in  high 
blood-pressure  and  increased  frequency  of  the  pulse,  due  in  part  to  its 
direct  influence  upon  the  heart  and  its  stimulating  action  upon  the 
vasomotor  centers.  The  brain  seems  to  be  especially  susceptible  to 
the  influence  of  caffein,  small  doses  sharpen  the  intellect  and  produce 
profundity  of  thought,  and  wakefulness.  The  drug  also  acts  as  a 
diuretic,  stimulating  the  secreting  structure  of  the  kidneys,  and  is 
quickly  eliminated  through  these  organs. 

Therapeutics. — Caffein  is  an  entirely  safe  drug  to  be  used  in  large 
dose,  hence  it  is  one  of  the  best  stimulants  to  employ  in  poisoning  by 
narcotic  drugs,  Uke  cocain,  opium,  etc.  Caffein  citrate  is  the  prepara- 
tion generally  used  because  it  is  more  soluble  than  caffein.  Strong 
black  coffee  is  also  used. 

The  drug  is  a  constituent  of  compound  acetanilid  powder,  N.F. 
Its  action  overcomes  the  depressant  effect  of  acetanilid  upon  the 
heart.  It  may  also  be  combined  with  phenacetin  or  a  bromid  and 
used  with  excellent  results  in  migraine  and  nervous  headache. 


172  STIMULANTS 

/ 

DIGITALIS— U.S.P. 

(Foxglove.) 

Digitalis  is  the  dried  leaves  of  Digitalis  purpurea,  a  biennial  plant 
growing  in  Central  and  Southern  Europe.  It  contains  several  princi- 
ples, all  of  which  are  glucosidal  in  character,  the  most  important 
being  digitalin,  digitoxin,  digitalein,  digitonin,  and  digitin.  The  first 
two  represent  more  or  less  imperfectly  the  action  of  digitalis  upon  the 
heartj  and  since  both  are  freely  soluble  in  alcohol  and  practically 
insoluble  in  water,  it  will  at  once  be  observed  that  the  most  active 
principles  of  the  drug  are  contained  in  the  tincture  and  fluid  extract, 
and  the  least  active  in  the  infusion;  all  of  which  preparations  of 
digitaHs  are  oflScial: 

Tinctvira  Digitalis,  U.S. P.     Dose,  5-20  min.  (0.3-1.3  mils). 
Fluidextractum    Digitalis,    U.S. P.     Dose,    1-2    min.    (0.06- 
0.12  mils). 
Infusum  DigitaHs,  U.S. P.     Dose,  1-4  fl.  dr.  (4.0-15.0  mils). 

Physiologic  Action. — DigitaHs  is  a  powerful  cardiac  stimulant. 
It  does  not  increase  the  rapidity  of  the  heart's  action;  it  rather  slows 
the  pulsations  and  raises  the  blood-pressure,  but  in  spite  of  this  the 
efficienc}'  of  the  contraction  is  increased  and  the  pulse  improved  in 
character.  In  therapeutic  doses  the  drug  has  practically  no  effect 
except  on  the  circulation.  The  slowing  of  the  pulse  results  from  a 
prolongation  of  the  diastole,  and  this  in  turn  is  due  to  stimulation  of 
the  vagi.  The  increased  blood-pressure  is  due  to  the  twofold  action 
of  the  drug,  that  of  securing  efficiency  by  the  direct  action  upon  the 
heart,  and  to  the  contraction  of  the  arterioles,  which  results  indi- 
rectly from  the  stimulation  of  the  vasomotor  center,  and  directly  from 
the  action  on  the  vessel-walls.  In  cases  of  low  arterial  pressure, 
when  the  urine  is  scanty,  digitalis  acts  as  a  diuretic. 

A  disadvantage  of  digitalis  medication  is  the  varying  strength  of 
the  crude  drug.  Pharmaceutic  chemists  have  attempted  to  remove 
this  disadvantage  by  standardizing  their  preparations.  The  follow- 
ing methods  of  standardization  are  most  extensively  used: 

1.  The  frog-lethal  dose  method. 

2.  The  frog-systohc  standstill  method,  of  which  there  are  several 
modifications. 

3.  The  guinea-pig  lethal  dose  method. 

4.  The  intravenous  cat  method. 

Poisoning  and  Treatment. — DigitaHs  is  more  rapidly  absorbed 
than  eHminated;  because  of  this,  cumulative  action  may  follow  the 
prolonged  use  of  the  drug  even  in  therapeutic  doses.     Toxic  s}Tnp- 


AMYLIS  NITRIS  1 73 

toms  may  result  from  this  source  or  from  the  ingestion  of  a  single 
poisonous  dose.  Poisoning  is  characterized  by  gastrointestinal  dis- 
turbances, abdominal  pains,  vomiting,  and  purging,  with  slow 
pulse,  feeble  respiration,  dilated  pupils,  headache,  delirium,  and 
stupor.  If  a  fatality  results,  it  is  generally  from  ten  to  forty-eight 
hours  after  the  ingestion  of  the  drug,  as  digitaUs  is  a  slow  poison.  In 
the  treatment  of  poisoning,  the  stomach-pump  should  be  employed. 
Tannic  acid  is  a  chemic  antidote  and  may  be  given.  Body  tempera- 
ture should  be  maintained  by  external  heat,  especially  applied  to  the 
abdomen.  AlcohoHc  stimulants  are  often  indicat-ed.  The  patient 
should  be  kept  in  the  recumbent  position,  not  being  allowed  even  to 
raise  his  hand  or  head  from  the  bed. 

Therapeutics. — The  chief  use  of  the  drug  in  dental  therapeutics 
is  as  a  cardiac  stimulant.  Hypodermic  injections  of  the  tincture  of 
digitalis  or  of  digitahn  may  be  employed  to  increase  the  efficiency  of 
the  heart's  action  in  syncope,  collapse,  and  poisoning  by  cardiac  de- 
pressants. It  is  best  here  to  use  the  drug  in  conjunction  with  stimu- 
lants which  act  more  quickly  (alcohoUc  stimulants).  The  drug  is 
contraindicated  in  cases  of  aneurysm. 

AMYLIS  NITRIS— U.S.P. 

(Amyl  Nitrite;  C5H11NO2.) 

Amyl  nitrite  is  prepared  by  the  action  of  nitric  acid  upon  amylic 
alcohol;  the  product,  being  a  highly  volatile  Hquid,  is  obtained  by 
distillation.     It  has  a  strong  ethereal  odor. 

Physiologic  Action. — Following  the  inhalation  of  amyl  nitrite 
there  is  a  marked  flushing  of  the  face,  due  chiefly  to  the  dilatation  of 
the  capillaries.  The  heart's  action  is  increased,  and  the  pulse  is  soft 
and  compressible.  There  is  a  marked  fall  in  blood-pressure  because 
of  the  dilatation  of  the  arterioles,  which  results  from  the  paralyzant 
action  of  the  drug  upon  the  muscle  fibers  found  in  these  structures. 
The  nitrites  cannot  be  regarded  as  powerful  cardiac  stimulants,  but 
their  action  is  equivalent  to  such,  for  by  dilating  the  arterioles  they 
largely  remove  the  resistance  against  which  the  heart  has  to  force 
the  blood,  thus  making  the  work  of  this  organ  much  easier  to  per- 
form. These  drugs,  therefore,  should  be  regarded  as  vasodilators, 
and  not  as  true  cardiac  stimulants;  but,  on  account  of  their  action  as 
vasodilators,  they  may  be  considered  circulatory  stimulants.  The 
drug  is  largely  eHminated  through  the  kidneys. 

Poisoning  and  Treatment. — In  toxic  doses  amyl  nitrite  produces 
an  exceedingly  rapid  and  weak  heart,  cyanosis,  slow  and  shallow 


174  STIMULANTS 

respiration,  vertigo,  headache,  and  disordered  vision,  death  result- 
ing from  cardiac  and  respiratory  failure.  In  the  treatment  of  poison- 
ing the  heart's  action  must  be  sustained.  Strychnin  and  digitahs  will 
be  foimd  useful.  Atropin  may  be  administered,  together  with  cold 
applications  to  the  head,  alcohoHc  stimulants,  and,  if  necessary, 
artificial  respiration.  Adrenahn  is  claimed  to  be  useful  as  it  contracts 
the  dilated  arterioles. 

Therapeutics. — Long^  states  that  it  is  to  be  regretted  that  the 
nitrites  have  been  considered  direct  heart  stimulants;  because  of  this 
they  are  extensively  used  in  cases  where  the  blood-pressure  is  already 
too  low  to  permit  efficiency  of  circulation,  as  in  chloroform  and  other 
drug  poisonings.  Amyl  nitrite  is  useful  to  relax  spasms  and  to  lower 
arterial  tension.  On  account  of  the  rapidity  with  which  the  drug  is 
absorbed  it  is  never  necessary  to  give  nitrites  hypodermically.  The 
effect  of  amyl  nitrite  may  be  obtained  almost  instantly  by  inhalation, 
and  a  dose  of  spirit  of  nitroglycerin  (1-3  min.— 0.06-0.2  mil)  placed 
under  the  tongue  will  produce  its  full  effect  in  less  than  five  minutes. 
Amyl  nitrite  may  be  obtained  in^glass  capsules  or  pearls,  containing 
the  requisite  dose  (2-5  min. — 0.13-0.3  mil),  which  are  easily  crushed 
in  a  handkerchief,  and  should  always  be  given  by  inhalation.  In  this 
manner  it  may  be  employed  with  benefit  to  reHeve  the  convulsions  of 
epilepsy,  tetanus,  uremia,  and  strychnin  poisoning.  The  drug  is  used 
in  syncope  and  collapse  from  other  causes,  but  the  diffusible  stimulants 
are  far  preferable. 

GLYCERYLIS  NITRAS 

(Nitroglycerin;    Glonoin;    Glyceryl    Trinitrate;   C3H5(N03)3-) 

Nitroglycerin  is  obtained  by  nitric  acid  or  a  mixture  of  nitric  and 
sulphuric  acid  on  dehydrated  glycerin.  It  occurs  as  a  clear,  colorless 
Hquid,  with  an  odor  and  taste  resembling  that  of  alcohol.  It  explodes 
with  great  force,  and  should  be  kept  in  a  cool  place,  away  from  Hghts 
and  fire.     It  is  official  in  the  following  form: 

Spiritus  Glycerylis  Nitratis,  U.S. P.  (Spirit  of  Nitroglycerin; 
an  alcoholic  solution  containing  i  per  cent,  by  weight  of 
Glyceryl  Trinitrate).    Dose,  1-3  min.  (0.06-0.2  mil.) 

Physiologic  Action  and  Therapeutics. — Nitroglycerin  is  prefer- 
able to  amyl  nitrite,  whose  action  it  resembles,  for  internal  adminis- 
tration. It  is  used  in  dentistry  as  a  cardiac  stimulant,  and  for  this 
purpose  it  may  be  found  as  a  constituent  of  local  anesthetic  solutions. 
It,  however,  is  far  inferior  to  strychnin  or  atropin  as  an  agent  to  over- 
come the  depressant  effect  of  cocain  upon  the  heart. 

^  Dental  Materia  Medica,  Therapeutics  and  Prescription  Writing. 


RESPIRATORY  STIMULANTS  1 75 

Nitroglycerin  is  a  valuable  drug  in  those  cases  where  it  is  desirable 
to  relieve  blood-pressure.  For  example,  when  it  is  deemed  neces- 
sary to  apply  arsenic  trioxid  to  a  pulp  which  is  in  an  inflammatory 
state,  the  engorged  capillaries  may  be  relieved  and  the  pain  mitigated 
by  the  administration  of  this  drug  (see  page  327). 

RESPIRATORY  STIMULANTS 

These  are  agents  which  increase  the  functional  activity  of  the  res- 
piratory centers  or  the  efficiency  of  the  respiratory  apparatus.  The 
chief  respiratory  stimulants  are: 

Belladonna  (Atropin).  Strychnin.* 

Ammonia.*  Caffein.* 

All  of  these  drugs  have  been  elsewhere  discussed  except  the  first- 
mentioned. 

BELLADONNA 

(Deadly  Nightshade.) 

Beiladonna  is  a  herbaceous  perennial  plant  growing  in  the  woods, 
chiefly  in  the  mountainous  districts  of  Central  and  Southern  Europe. 
Both  the  dried  leaves  {Belladonna  Folia,  U.S. P.)  and  the  dried  root 
{Belladonna  Radix,  U.S. P.)  of  Atropa  Belladonna  are  official.  The 
drug  contains  an  important  alkaloid,  atropin,  to  which  its  physiologic 
activity  is  due.  The  average  dose  of  the  powdered  leaves  and  root  is 
I  gr.  (0.06  Gm.).     The  following  preparations  are  official: 

Tinctura   Belladonnse   Foliorium,    U.S. P.     Dose,   5-20  min. 

(0.3-T.3  mils). 

Extractum  Belladonnae  Foliorium,  U.S. P.     Dose,  y^-Vi  gr. 

(0.008-0.016  Gm.). 

Emplastrum  Belladonnae,  U.S. P. 

Unguentum  Belladonnas,  U.S. P.  (10  per  cent,  from  Extract). 

Fluidextractum  Belladonnae  Radicis,  U.S. P.     Dose,  1-3  min. 

(0.06-0.2  mil). 

Linimentum  Belladonnae,  U.S. P.  (contains  Camphor,  5  parts; 

fluid  extract  of  Belladonna  Root,  95  parts). 

The  action  of  belladonna  is  due  entirely  to  atropin  which  it  con- 
tains.    This  alkaloid  is  official. 

ATROPINA— U.S.P. 

Atropin  occurs  in  the  form  of  white,  acicular  crystals,  or  a  crys- 
talline powder,  odorless,  having  a  bitter,  acrid  taste;  soluble  in  455 


176  STIMULANTS 

parts  of  water,  2  parts  of  alcohol,  25  parts  of  ether,  i  part  of  chloro- 
form, and  about  27  parts  of  glycerin,  at  25°C.  One  salt  of  atropin  is 
ofl5.cial  (Atropinas  Sulphas,  U.S. P.),  and  in  appearance  resembles  the 
alkaloid  itself,  except  that  it  is  more  freely  soluble  in  water.  The 
average  dose  of  atropin  or  of  its  salt  is  3^120  gr-  (0.0005  Gm.). 

Physiologic  Action. — The  action  of  belladonna  is  dependent  upon 
the  amount  of  contained  atropin.  AppHed  locally  in  combination 
with  absorbable  substances — alcohol,  camphor,  animal  fat,  glycerin, 
etc. — atropin  acts  as  a  depressant  to  all  highly  organized  tissues, 
exerting  an  analgesic  and  antisecretory  influence.  ^Medicinal  doses 
of  atropin,  taken  internally,  produce  dryness  of  the  throat,  dilatation 
of  the  pupils,  quickening  of  the  pulse,  deepening  of  the  respirations, 
and  occasionally  talkative  delirium  and  erythematous  rash.  It  is 
well  to  remember  here  that  medicinal  doses  stimvdate  the  respiratory 
center,  while  toxic  doses  paralyze  it. 

The  saUvary  secretion  is  lessened  through  paralysis  of  the  periph- 
eral endings  of  the  secretory  fibers  only  of  the  chorda  tympani  nerve 
in  the  submaxillary  gland  (Butler).  The  drug  also  diminishes  all  of 
the  secretions  of  the  body,  and  its  elimination  is  effected  chiefly 
through  the  kidneys^ 

Poisoning  and  Treatment. — The  characteristic  symptoms  of 
atropin  poisoning  are  dryness  of  the  throat,  dilated  pupils,  rapid  pulse, 
quick  respiration,  uneasiness,  talkative  delirium,  erythematous  rash, 
with,  ultimately,  stupor,  collapse,  and  death  from  paralysis  of  the 
respiratory  center.  In  the  treatment  of  poisoning  the  stomach  should 
be  evacuated  and  then  washed  out  with  solutions  of  tannic  acid — the 
chemic  antidote.  Cardiac  and  other  respiratory  stimulants  (caffein) 
should  be  cautiously  administered  as  the  symptoms  indicate. 

Therapeutics. — Atropin  is  one  of  the  best  remedies  at  our  com- 
mand for  controlKng  the  secretions  of  the  body.  In  cases  where  it 
is  necessary  to  keep  the  field  of  operation  dry,  as  in  treating  and  filling 
teeth  where  the  rubber  dam  cannot  be  successfully  adjusted,  atropin 
may  be  administered  a  few  hours  previous  to  operating  with  excellent 
results.  In  salivation  from  mercury  the  drug  is  hkewise  useful.  In 
hyperidrosis  of  the  hands  and  feet  preparations  of  belladonna  are  used 
both  externally  and  internally.  Combined  with  camphor  and  other 
drugs,  extract  of  belladonna  is  a  useful  remedy  in  acute  coryza. 
Probably  the  greatest  use  atropin  has  in  dental  therapeutics  is  in  the 
treatment  of  shock  and  collapse  from  local  and  general  anesthetics, 
and  also  in  the  treatment  of  poisoning  from  narcotic  drugs.  In  these 
cases  atropin  sulphate,  hypodermically  administered,  stands  next  to 
strychnin  and  its  salts. 


GASTRIC  STIMULANTS  177 

Liniment  of  belladonna  is  a  valuable  remedy  in  the  treatment  of 
neuralgia. 

GASTRIC  STIMTJLANTS 

Gastric  stimulants,  called  also  stomachics,  are  agents  which  sharpen 
the  appetite  and  promote  the  functional  activity  of  the  stomach. 
The  gastric  stimulants  are  called  "bitter  tonics/'  and  they  include 
the  following: 

Gentian.  Cinchona.* 

Wild  Cherry.  Hydrastis.* 

Nnx  Vomica.* 

GENTIANA— U.S.P. 
(Gentian.) 

Gentian  is  the  dried  rhizome  and  roots  of  Gentiana  lutea,  a  small 
perennial  plant  indigenous  to  the  mountainous  districts  of  Central 
Europe.  It  contains  a  bitter  glucosid,  gentiopicrin,  to  which  its 
stomachic  property  is  due.  The  average  dose  is  15  gr.  (i.o  Gm.). 
The  official  preparations  are : 

Tinctura   Gentianse  Composita,  U.S.P.    (10  per  cent,  with 

Orange  Peel  and  Cardamon  Seed).     Dose,  1-2  fl.  dr.  (4.0-8.0 

mUs) . 

Fluidextractum  Gentianae,  U.S.P.     Dose,  i5-3omin.  (1.0-2.0 

mUs). 

Extractum  Gentianae,  U.S.P.     Dose,  2-10  gr.  (0.13-0.6  Gm.). 

Infusum  Gentianae  Compositum  (Nonofficial).     Dose,  K  to  i 

fl.  oz.  (15.0-30.0  mUs). 

Physiologic  Action  and  Therapeutics. — The  action  of  gentian  is 
due  to  the  bitter  glucosid  which  it  contains,  and  Hke  all  bitter  tonics 
its  effect  is  immediate,  due  to  the  local  action  of  the  drug.  It  aug- 
ments the  secretions  from  the  salivary  and  gastric  glands,  and  thus 
aids  digestion  and  improves  nutrition.  There  is  an  intimate  relation- 
ship between  the  stomach  and  the  senses  of  taste  and  smell,  and  any- 
thing bitter  in  the  mouth  reflexly  stimulates  the  gastric  secretion. 

Gentian  is  not  much  employed  in  dental  practice.  It  may  be  con- 
sidered one  of  the  most  reUable  bitter  tonics.  In  pyorrhea  akeolaris 
associated  with  neuralgia  due  to  a  general  atonic  condition,  the 
compound  tincture  of  gentian  may  be  advantageously  combined  with 
tincture  of  valerian  (equal  parts  of  the  two)  and  given  before  meals 
in  teaspoonful  doses.  Where  the  pyorrhea  has  caused  indigestion  an 
antacid,  hke  sodium  bicarbonate,  may  be  combined  with  some  prepa- 
ration of  gentian;  because  of  the  insolubility  of  sodium  bicarbonate 
in  alcohol,  the  compound  infusion  of  gentian  should  be  selected.     A 


lyS  STIMULANTS 

useful  combination  is:  Sodium  bicarbonate,  3=-^  dr.  (2.0  Gm.);  com- 
pound infusion  of  gentian,  3  fl.  oz.  (90.0  mils).  This  may  be  given 
in  tablespoonful  doses,  before  meals. 

PRUNUS  VIRGINIANA— U.S.P. 

(Wild  Cherry.) 

Prunus  virginiana  is  the  hark  of  Prunus  serotina,  a  large  tree  in- 
digenous to  North  America.  It  contains  tannic  acid,  a  bitter  princi- 
ple, a  ferment,  emulsin,  and  a  glucosid,  amygdalin.  In  the  presence 
of  the  ferment  and  water  the  glucosid  is  broken  up  into  hydrocyanic 
acid  and  a  volatile  oil.  The  average  dose  of  wild  cherry  bark  is  30  gr. 
(2.0  Gm.).     The  following  preparation  is  official: 

Syrupus  Pruni  Virginianae,  U.S.P.     Dose,  1-4  fl.  dr.  (4.0-15.0 
mils). 

Physiologic  Action  and  Therapeutics. — Wild  cherry  is  a  bitter 
tonic.  It  might  also  be  considered  a  sedative  tonic.  While  it  is 
pecuUarly  bitter,  it  is  not  unpleasant,  and  is  well  tolerated  by  the 
stomach.  The  syrup  of  wild  cherry  is  a  common  ingredient  in 
"cough-mixtures,"  and  is  supposed  to  quiet  the  cough  and  allay  the 
irritabiUty  of  the  nervous  system  in  bronchial  affections.  This  effect  is 
doubtless  due  to  the  hydrocyanic  acid  which  it  contains.  The  syrup 
has  an  agreeable  taste  and  serves  as  an  excellent  vehicle  for  unpal- 
atable drugs. 

The  other  stomachics  have  been  discussed  under  other  headings. 

RESTORATIVE  STIMULANTS 

These  are  agents  which  maintain  or  restore  the  bodily  functions. 
The  principal  restorative  stimulant  is: 

LIQUOR  SODII  CHLORIDI  PHYSIOLOGICUS,  U.S.P. 

(Physiologic  Salt  Solution;  Normal  Salt  Solution.) 

This  is  a  solution  of  8.5  parts  of  sodium  chlorid  in  1,000  parts  of 
sterile  water,  and  closely  corresponds  in  salinity  to  blood-serum.  It 
is  regarded  as  a  valuable  stimulant  in  cases  of  shock  or  collapse,  espe- 
cially from  loss  of  blood  by  hemorrhage.  It  is  injected  intravenously 
by  permitting  the  solution,  quite  hot,  to  run  slowly  through  a  large- 
sized,  long  hypodermic  needle  from  a  fountain  syringe  into  the  lumbar 
region  or  underneath  the  breast.  From  2  fl.  oz.  (60.0  mils)  to  10  fl.  oz. 
or  even  i  qt.  (300.0-1,000  mils)  may  be  used  at  frequent  intervals. 
Sollmann^  states  that  the  action  is  only  short,  and  the  injection  must 

1  A  Text-Book  of  Pharmacology, 


MISCELLANEOUS    STIMULANTS  1 79 

therefore  be  repeated.  The  restoration  is  brought  about  by  the  sub- 
stitution of  this  fluid  for  the  blood-serum.  The  solution  is  an  excel- 
lent bland  remedy  to  be  used  in  establishing  sinuses  associated  with 
alveolar  abscesses,  and  also  as  a  vehicle  for  local  anesthetics  and  other 
agents  (adrenalin,  etc.).  For  making  local  anesthetic  solutions, 
Ringer  tablets  are  frequently  added  to  sterile  distilled  water  to  make 
an  isotonic  solution.  The  Ringer  tablet  "B",  which  is  generally 
employed,  contains  sodium  chlorid  %  gr.  (0.05  Gm,),  calcium  chlorid 
3^5  gr.  (0.004  Gm.),  and  potassium  chlorid  3^o  gr-  (0.002  Gm.).  One 
Ringer  tablet  "B"  dissolved  in  23^  fl.  dr.  (10. o  mils)  of  water  makes  a 
0.56  per  cent,  solution  of  the  salts,  which  with  the  addition  of  the 
anesthetic  agent  approximates  closely  the  specific  gravity  of  the 
blood-serum,  making  the  solution  isotonic. 

According  to  Dr.  Alexis  Carrel  of  the  Rockefeller  Institute  for 
Medical  Research,  and  Dr.  W.  Crile,  of  Cleveland,  Ohio,  and  others, 
the  latest  method  of  treating  infected  wounds  consists  in  thoroughly 
irrigating  the  part  with  Dakin's  hyperchlorous  acid  solution,  and  then 
exposing  the  wound  to  light  from  electric  lamps  placed  in  paste- 
board cones  on  metal  hoods  suspended  from  an  adjustable  frame. 
The  amount  of  light  and  the  proximity  of  the  lamps  to  the  wound 
are  governed  by  the  comfort  of  the  patient.  When  coagulated 
serum  develops,  Crile  suggests  a  hot  pack  for  half  an  hour  with 
Wright's  hypertonic  solution.  A  hypertonic  solution  is  one  whose 
osmotic  tension  exceeds  that  of  the  blood-serum.  The  formulae  for 
Danny's  and  Wright's  solutions  are  here  given: 


Dakin's  Solution. — 

Dry  sodium  carbonate 

200  Gm. 

Chlorinated  lime 

140  Gm, 

Tap  water 

10  L. 

Mix  and  filter  through  cotton. 

Add  40  gm.  boric  acid. 

Wright's  Solution.— 

Sodium  chlorid 

3  parts. 

Sodium  citrate 

I  parts. 

Water 

96  parts. 

MISCELLANEOUS  GROUP 

There  are  several  drugs  which  have  a  peculiar  action  upon  "the 
nervous  system  other  than  those  thus  far  discussed  under  the  various 
headings  of  general  remedies.  Some  of  these  drugs  stimulate,  while 
others  depress  the  nervous  system.  They  will  be  considered  here 
under  this  heading.  Those  of  importance  to  dentists  are: 
Gelsemium.  Valerian. 


l8o      -  STIMULANTS 

GELSEMIUM— U.S.P. 

(Yellow  Jasmine.) 

Gelsemimn  is  the  dried  rhizome  and  roots  of  Gelsemium  semper- 
virens,  a  climbing  plant  growing  in  the  moist  woods  of  southern 
United  States.  It  contains  two  alkaloids — gelsemin  and  gelseminin — 
the  former  stimulates,  while  the  latter  depresses  the  nervous  system. 
The  general  effect  of  the  drug  is  the  result  of  a  blending  of  the  actions 
of  the  two  alkaloids,  although  in  man  gelseminin  appears  to  be  more 
potent.  The  average  dose  of  powdered  gelsemium  is  3^^  gr.  (0.03 
Gm.).     The  official  preparations  are : 

Tinctura  Gelsemii,  U.S.P.     Dose,  10  to  30  min.  (0.6-2.0  mils). 

Fluidextractum  Gelsemii,  U.S.P.     Dose,  2-10  min.  (0.13-0.6 

mU).  , 

Extractum  Gelsemii,  U.S.P.     Dose,  }^  gr.  (o.oi  Gm.). 

Physiologic  Action  and.  Therapeutics. — Gelsemium  has  a  distinct 
action  upon  sensory  nerves  and  is  useful,  therefore,  in  painful  affec- 
tions. In  large  doses  it  depresses  the  spinal  cord,  especially  its  motor 
neurons.  The  drug  is  used  in  trifacial  neuralgia,  and  appears  to  be 
most  serviceable  when  the  neuralgia  arises  from  diseased  conditions  of 
the  teeth.  The  fluid  extract  is  the  preparation  generally  employed, 
although  Marshall^  prefers  gelseminin  sulphate,  giving  >^o  gr-  (0.002 
gm.)  every  two  hours  until  the  constitutional  eff'ects  are  produced. 
This  salt  naturally  would  be  more  effective  in  neuralgic  conditions 
than  gelsemium  preparations,  as  it  is  the  alkaloid  that  depresses  the 
nervous  system ;  the  other  alkaloid  (gelsemin)  stimulates. 

Poisoning  and  Treatment. — The  toxic  symptoms  of  gelsemium  are 
drooping  eyeUds,  disordered  \-ision,  frontal  headache,  falhng  of  the 
jaw,  muscular  weakness,  slow  respiration,  and,  finally,  collapse.  In 
the  treatment  of  poisoning  the  stomach  should  be  evacuated,  tannic 
acid  administered  as  the  chemic  antidote,  and  collapse  combatted 
with  such  stimulants  as  strychnin,  whisky,  and  ammonia. 

VALERIANA— U.S.P. 

(Valerian.) 

Valerian  is  the  dried  rhizome  and  roots  of  Valeriana  officinalis,  a 
herbaceous,  perennial  plant,  native  of  Europe.  It  contains  valerianic 
acid  and  a  volatile  oil.  The  average  dose  is  30  gr.  (2.0  Gm.).  The 
following  preparations  are  official: 

Tinctura  Valerianae,  U.S.P.     Dose,  1-2  fl.  dr.  (4.0-8.0  mils). 
Tinctura  Valerianae  Ammoniata,  U.S.P.     Dose,  1-2  fl.  dr. 
(4.0-8.0  mils). 
'  Injuries  and  Surgical  Diseases  of  the  Face,  ]Mouth  and  Jaws. 


ALTERAXrVES  AXD  RESTORATR'ES  l8l 

Physiologic  Action  and  Therapeutics. — The  principal  action  of 
valerian  is  upon  the  nervous  system,  and  it  may  be  classed  as  a 
nervine  in  that  it  produces,  in  moderate  dose,  a  sedative  effect  upon 
the  brain  and  spinal  cord.  In  pyorrhea  akeolaris  associated  with 
more  or  less  neuralgia  due  to  a  general  atonic  condition  it  may  be  com- 
bined with  gentian  with  excellent  results. 

ALTERATIVES  AND  RESTORATIVES 

Altei*atives  are  agents  which  promote  metabolic  processes  and 
thus  counteract  morbid  conditions.  They  are  closely  related  to 
restoratives  in  that  both  classes  promote  the  processes  of  nutrition 
and  aid  metabolism.  The  latter  class  includes  foods,  hematics,  and 
tonics. 

Foods  are  substances  which,  when  introduced  into  the  body, 
supply  material  with  which  some  structure  is  rebuilt  or  some  vital 
process  is  maintained.  They  differ  from  medicines  in  that  the 
latter  modify  vital  processes,  but  furnish  no  material  to  renew  the 
structures  of  the  body. 

Hematics  or  hematinics  are  agents  which  increase  the  hematin  in 
the  blood  and  restore  or  maintain  bodily  functions  by  enriching  the 
red  blood-corpuscles.     The  compounds  of  iron  are  the  chief  hematics* 

Tonics  are  agents  which  improve  the  tone  and  impart  strength 
and  energy  to  the  tissues.     The  main  tonics  are: 

Iron  and  Compounds.  Hypophosphites. 

Phosphorus.  Cod-liver  Oil. 

Calcium  Phosphate.  Nux  Vomica.* 

Cinchona.* 

The  principal  alteratives  are : 

Potassium  lodid.  Sarsaparilla. 

Mercury.  Echafolta. 

Arsenic*  Calx  Sulphurata. 

Gold  and  Sodium  Chlorid. 

FERRUM— U.S.P. 

(Iron;  Fe.) 

Metallic  iron  is  of&cial  in  the  form  of  line,  bright  wire. 

Physiologic  Action  and  Therapeutics. — Iron  is  an  essential  ele- 
ment of  the  body  and  may  be  regarded  as  a  food  as  well  as  a  medicine. 
It  enters  as  an  essential  constituent  (0.4  per  cent.)  into  a  pecuHar 
proteid  body — the  hemoglobin  of  the  blood.  It  is  through  the  iron 
compounds  of  the  body  that  the  greater  portion  of  the  oxidizing  func- 
tions of  the  various  cells  are  carried  on.     In  a  healthy  state  of  the 


102  ALTER-\Tr\'ES    AXD    RESTORATR^ES 

body,  when  the  processes  of  mastication,  digestion,  assimilation,  and 
nutrition  are  normal,  there  is  a  sufficient  amount  of  iron  furnished  by 
the  mixed  diet  to  answer  all  physiologic  requirements;  but  in  many 
pathologic  conditions  there  is  a  deficiency  of  iron,  and  the  element 
must  be  furnished  in  the  form  of  selected  food  or  medicine.  There 
is  a  difference  of  opinion  as  to  whether  metalHc  iron  can  be  assimilated 
by  the  body;  some  authorities  claiming  that  it  is  necessary  first  to  have 
the  iron  organized  by  plant  Kfe  into  compounds  containing  it,  while 
others  claim  that  this  is  not  necessarily  essential  to  the  assimilation 
of  the  metal.  Bunge  supposed  that  only  "organic  iron"  could  be 
absorbed  and  assimilated  by  the  body,  the  reputed  action  of  inor- 
ganic iron  being  altogether  indirect  and  due  to  its  local  efi'ect  on  the 
aHmentary  canal.  This  theory  was  modified  by  Abderhalden  to 
the  effect  that  inorganic  iron,  while  it  could  not  be  converted  into 
hemoglobin,  nevertheless  stimulated  the  conversion  of  "organic 
iron."  Later  work,  however  (Tartakowski),  seems  to  prove  con- 
clusively that  inorganic  iron  is  assimilated  and  converted  into  hemo- 
globin and  in  so  far  is  therapeutically  fully  equal  to  natural  complex 
iron  compounds.  IMany  authors  and  practitioners,  nevertheless, 
still  adhere  to  the  theories  of  Bunge  and  Abderhalden.  There  can 
be  no  question  regarding  the  local  and  astringent  action  of  most  in- 
organic preparations,  which  is  absent  in  most  of  the  complex  iron 
compounds.  These  local  actions  may  be  desirable  in  some  cases  and 
undesirable  in  others.  This  aids  in  determining  the  selection  of  the 
particular  iron  preparation  most  suitable  for  each  individual  patient. 
^NletalUc  iron  is  not  used  as  a  therapeutic  agent  in  dentistry.  In 
medicine  it  is  extensively  employed  in  diseases  which  afl'ect  the  cir- 
culation, as  anemia  and  chlorosis.  ]Many  iron  compounds  are  used  in 
dentistry  and  will  here  be  considered. 

Iron  Compounds. — Iron  forms  two  series  of  compounds —/err<9W5 
and  ferric.  The  former  are  white  when  freshly  precipitated  in  the 
absence  of  oxygen,  but  when  moist  and  exposed  to  air  they  readily 
absorb  oxygen  and  gradually  change  into  ferric  compounds,  which  are 
usually  reddish-brown  in  color.  In  this  change  there  is  an  array  of 
four  distinct  colors — white,  green,  black,  and  brown,  respectively — 
and  in  the  blending  of  these  colors  there  may  be  produced  every 
variety  of  shades  seen  in  discolored  teeth.  As  it  is  quite  generally 
conceded  that  iron  is  the  most  important  element  to  be  considered  in 
the  many  factors  entering  into  the  complicated  problem  of  tooth 
discoloration  from  pulp  decomposition,  the  above  fact  should  be 
remembered. 

With  the  exception  of  the  carbonate,  the  hydroxid,  and  the  hypo- 


FERRI   SULPHAS  1 83 

phosphite,  all  of  the  compounds  of  iron  are  freely  soluble  in  water, 
but  insoluble  in  alcohol.  The  so-called  scaled  salts  are  all  ferric  com- 
pounds of  phosphoric  acid,  or  the  organic  acids,  citric  and  tartaric; 
they  are  rendered  more  soluble  in  combination  with  citrates,  tar- 
trates, and  phosphates  of  the  respective  alkahes — ammonium, 
potassium,  and  sodium — and  some  are  known  as  "soluble"  salts. 
The  scale  salts  are  comparatively  free  from  astringency,  usually  well 
borne  by  the  stomach,  and  are  used  in  medicine  as  mild  and  agreeable 
hematinics.  The  dose,  with  one  exception  (that  containing  strych- 
nin), is  4  gr.  (0.25  Gm.).  The  official  Latin  titles  do  not  distinguish 
between  the  ferrous  and  ferric  compounds,  but  they  are  so  distin- 
guished in  the  English  titles.  Iron  is  used  in  medicine:  (i)  in  the 
form  of  metalHc  or  elementary  iron  (Reduced  Iron,  U.S. P.);  (2)  in 
the  ferrous  or  unoxidized  form  of  combination — responding  to  tests 
for  ferrous  ions  (ferrous  carbonate  in  mass  of  ferrous  carbonate  and 
pill  of  ferrous  carbonate,  ferrous  iodid  in  syrup  of  ferrous  iodid, 
U.S. P.);  (3)  in  trivalent  or  oxidized  form,  the  ferric  compounds — re- 
sponding to  tests  for  ferric  ions  (ferric  chlorid  in  tincture  of  ferric 
chlorid,  U.S. P.);  and  (4)  complex  compounds  of  iron.  Complex 
(masked  or  nonionic)  iron  compounds  are  those  compounds  of  iron 
wherein  iron  is  part  of  a  radical,  and  whose  solutions  do  not  respond 
to  the  ordinary  tests  for  ferrous  or  ferric  ions.  Such  compounds  of 
iron  do  not  have  the  astringent  taste  of  simple  iron  solutions.  As 
they  are  not  decomposed  by  gastric  digestion,  they  are  also  devoid  of 
gastric  effects;  but,  on  the  other  hand,  it  has  been  claimed  that  cer- 
tain hemoglobin-like  compounds  escape  absorption  altogether.  It 
should  be  remembered  that  "masked"  iron  can  often  be  administered 
in  sufficient  amounts  and  most  economically  by  selecting  a  dietary 
rich  in  iron,  such  as  red  meat,  egg-yolk,  green  vegetables,  whole 
wheat,  etc.  The  iron  compounds  used  in  dental  therapeutics  here 
follow. 

FERRI  SULPHAS— U.S.P. 

(Ferrous  Sulphate;  Green  Vitriol;  FeS04.7H20.) 

Ferrous  sulphate  occurs  in  the  form  of  bluish-green,  effiorescent 
prisms,  odorless,  having  a  sahne,  stj'ptic  taste.  It  is  freely  soluble  in 
water,  insoluble  in  alcohol.  The  average  dose  is  i}4  gr.  (o.i  gm.). 
The  official  preparations  are : 

Ferri   Sulphas  Exsiccatus,  U.S. P.     Dose,  1-3  gr.  (0.06-0.2 

Gm.). 

Ferri  Sulphas  Granulatus,  U.S. P.     Dose,  1-3  gr.  (0.06-0.2 

Gm.). 


184  ALTERATIVES   AND   RESTORATIVES 

Physiologic  Action  and  Therapeutics. — Iron  sulphate  is  an  active 
astringent.  It  may  be  applied  to  canker  sores,  but  is  inferior  to  cop- 
per sulphate.  It  is  frequently  used  as  a  deodorant  for  privies  and 
cesspools. 

FERRI    SUBSULPHAS     (Nonofficial) 
(Ferric  Subsulphate;  Basic  Ferric  Sulphate;  Monsel's  Salt; 

Fe40(S04)5.) 

Ferric  subsulphate  occurs  as  a  yellow,  hygroscopic,  astringent 
powder,  freely  soluble  in  water.     There  is  one  official  preparation: 

Liquor   Ferri   Subsulphatis,   U.S.P.    (Monsel's   Solution). 
Dose,  3—5  min.  (0.2-0.3  mil). 

Physiologic  Action  and  Therapeutics. — Monsel's  salt  or  the 
official  solution  (Monsel's  solution)  is  a  prompt  and  powerful  styptic, 
and  as  such  it  has  long  been  used  in  dentistry  to  control  hemorrhage 
following  the  extraction  of  teeth.  When  the  hemorrhage  proceeds  from 
a  tooth-socket  it  is  better  to  use  the  salt  than  the  solution,  for  the 
reason  that  the  hard  black  clots  formed  by  the  latter  may  conceal  the 
deep-seated  hemorrhage.  The  salt  can  be  incorporated  in  moist 
cotton  and,  after  washing  the  socket,  the  medicated  cotton  should  be 
packed  tightly  into  it.  Sometimes  it  is  necessary  to  hold  the  packing 
firmly  for  some  time  in  order  to  control  the  hemorrhage. 

FERRI  CHLORIDUM— U.S.P. 

(Ferric  Chlorid;  Iron  Perchlorid;  Fe2Cl6.i2H20.) 

Ferric  chlorid  occurs  in  orange-yellow,  crystalUne  pieces,  having 
an  astringent  taste.  It  is  a  highly  deHquescent  salt,  and  therefore 
freely  soluble  in  water,  also  in  alcohol.  The  official  preparations 
are: 

Liquor  Ferri  Chloridi,  U.S.P.     Dose,  3-10  min.  (0.2-0.6  mil). 

Tinctura  Ferri  Chloridi,  U.S.P.     Dose,  5-30  min.  (0.3-2.0 

mils). 

Liquor  Ferri  at  Ammonii  Acetatis,  U.S.P.     Dose,  1-4  fl.  dr. 

(4.0-15.0  mils). 

Physiologic  Action  and  Therapeutics. — Ferric  chlorid  is  an 
active  astringent  and  styptic.  It  is  employed  in  the  control  of 
hemorrhage,  after  the  extraction  of  teeth,  removal  of  small  growths,  etc. 

As  a  styptic  in  dental  therapeutics,  it  is  inferior  to  Monsel's 
solution  or  salt.  The  tincture  has  a  deleterious  action  upon  the 
teeth,  and  should  be  used  about  the  mouth  with  caution. 


FEE.RI    CARBONAS FERRI    HYDROXIDUM    CUM    MAGNESII    OXIDO        185 

Ferrmn  Dialysatum  (Dialysed  Iron). — This  is  a  nonof&cial  prepa- 
ration of  iron  oxychlorid  from  which  acidulous  matter  has  been 
separated  by  dialysis,  hence  the  name,  dialysed  iron.  It  is  a  dark  red, 
neutral  liquid,  without  odor  or  taste.  It  has  been  employed  freely  as 
a  local  antidote  in  arsenical  poisoning.  Dentists  have  been  prone 
to  rely  upon  this  agent  when  other  remedies  would  serve  better  (see 
p.  329). 

FERRI  CARBONAS  (Nonofficial) 
(Ferrous  Carbonate;  FeCOs.) 

Ferrous  or  iron  carbonate  is  an  unstable  compound  which  is 
readily  converted  into  ferric  hydroxid  (^hydrate)  when  moist  and  ex- 
posed to  air — a  characteristic  of  most  ferrous  compounds.  The  salt 
may  be  protected  from  oxidation  and  enters  into  the  following  official 
preparations : 

Ferri  Carbonas  Saccharatus,  U.S. P.     Dose,  5-15  gr.  (0.3-1.0 
Gm.). 

Massa  Ferri  Carbonatis,  U.S. P.     (Vallet's  Mass).     Dose,  3-5 
gr.  (0.2-0.3  Gm.). 

PHulae  Ferri  Carbonatis,  U.S.P.    (Blaud's  Pills,  each  contain- 
ing not  less  than  i  gr.  (0.069  Gm.)  of  pure  Ferrous  Carbonate). 
Dose,  1-3  pills. 

Physiologic  Action  and  Therapeutics. — Ferrous  carbonate  acts  as 
a  tonic,  and  the  preparations  containing  it,  being  free  from  agtrin- 
gency,  may  be  used  whenever  iron  is  demanded  by  the  tissues.  The 
preparations  are  especially  useful  in  anemia. 

FERRUM  REDUCTUM— U.S.P. 

(Reduced  Iron;  Iron  by  Hydrogen.) 

Reduced  iron  occurs  as  a  fine,  grayish-black,  insoluble  powder, 
without  odor  or  taste.  It  should  contain  not  less  than  90  per  cent. 
of  metallic  iron.  It  is  a  valuable  hematinic,  as  it  is  free  from  astrin- 
gency  and  has  little  tendency  to  cause  constipation.  The  average 
dose  is  I  gr.  (0.06  Gm.)  given  in  the  form  of  pills,  capsules,  or 
lozenges. 

FERRI  HYDROXIDUM  CUM  MAGNESH  OXIDO— U.S.P. 

(Ferric  Hydroxid  with  Magnesium  Oxid.) 

Ferric  hydroxid  with  magnesium  oxid  is  made  by  adding  ammonia 
water  to  a  solution  of  ferrous  sulphate,  collecting  and  washing  the 


1 86  ALTERATIVES  AND  RESTORATIVES 

precipitate,  when  magnesium  oxid  is  added  in  excess.  The  prepara- 
tion is  used  exclusively  as  an  internal  antidote  in  arsenical  poisoning. 
It  should  be  freshly  made  and  given  freely,  while  still  moist,  in  table- 
spoonful  doses  or  more  every  few  minutes.  The  average  dose  is  4 
fl.  oz.  (120.0  mils). 

FERRI  lODroUM  (Nonofficial) 
(Iron  lodid;  Fel2.) 

Ferrous  iodid  occurs  in  grayish- white,  crystalline  masses;  soluble 
in  water  with  partial  decomposition.  It  enters  as  an  essential  con- 
stituent into  the  following  official  preparations: 

Syrupus  Ferri  lodidi,  U.S. P.  (5  per  cent.).     Dose,  5-60  min. 

(0.3-4.0  mils.). 

Pilulas  Ferri  lodidi,  U.  S.  P.  (i  gr.  o.g6  gm.,  each).     Dose,  1-3 

pills. 

Physiologic  Action  and  Therapeutics. —Iron  iodid  acts  as  an 
alterative,  and  as  such  is  used  in  certain  syphilitic  conditions.  The 
syrup  is  injurious  to  the  tooth  structure,  and  it  should  be  taken 
through  a  tube,  or  given  well  diluted  with  instructions  to  thoroughly 
rinse  the  mouth  after  its  administration. 

FERRI  HYPOPHOSPHIS  (Nonofficial) 
(Ferric  Hypophosphite.) 

This  salt  occurs  as  a  white  powder,  odorless,  and  practically  taste- 
less. It  is  but  sparingly  soluble  in  water.  The  average  dose  is  8  gr. 
(0.5  Gm).     It  is  contained  in  the  following  preparation: 

Syrupus  Hypophosphitum  Compositus,  N.  F.     Dose,  1-4  fl. 
dr.  (4.0-15.0  mils). 

This  preparation  is  adopted  from  the  National  Formulary,  and  is 
similar  to  a  number  of  proprietary  syrups  of  hypophosphites.  The 
preparation  is  used  as  an  alterative  and  hematinic. 

PHOSPHORUS— U.S.P. 

(P.) 

Phosphorus  occurs  as  a  translucent,  nearly  colorless  soHd,  of  a 
waxy  luster,  and  at  ordinary  temperatures  having  about  the  con- 
sistence of  beeswax.  When  kept  for  some  time  the  surface  becomes 
red  and  occasionally  black.  When  exposed  to  air  it  emits  white 
fumes,  visible  in  the  dark,  which  have  an  odor  somewhat  like  garlic. 


PHOSPHORUS  187 

Upon  prolonged  exposure  to  air  it  takes  fire  spontaneously.  The 
drug  should  be  carefully  kept  under  water,  in  which  it  is  practically 
insoluble,  in  strong,  well-closed  vessels.  The  average  dose  is  3^20 
gr.  (0.0005  Gm.).     The  following  preparation  is  offi.cial: 

Pilulae  Phosphor],   U.S. P.    (each  pill   contains   Koo   gr.- 
0.0006  Gm.).     Dose,  1-3  pills. 

Physiologic  Action. — Phosphorus  stimulates  the  bone-forming 
tissues,  when  given  in  small  doses,  rendering  the  bones  more  dense, 
and  diminishing  the  cancellous  structure;  if  the  administration  of  the 
drug  is  continued,  the  marrow-cavity  becomes  more  or  less  obliter- 
ated. There  has  been  a  difference  of  opinion  among  investigators 
as  to  how  this  result  was  brought  about.  Some  believed  that  an 
excess  of  phosphates  was  deposited,  while  others  felt  that  it  was  due 
to  a  specific  irritation  of  the  bone-forming  cells,  causing  stimula- 
tion. The  latter  theory  is  more  nearly  correct,  for  Wegner  has  shown 
by  a  series  of  experiments  on  growing  animals  fed  with  phosphorus, 
but  deprived  of  phosphates,  that  the  same  hyperplasia  in  the  bones 
resulted,  but  that  the  new  tissue  was  soft  and  gelatinous  instead 
of  hard.  The  dominant  action  of  phosphorus  is  upon  the  osseous 
system.  Stevens  claims,  however,  that  there  is  considerable  clinical 
testimony  to  show  that  the  drug  improves  the  nutrition  of  other 
tissues,  especially  of  the  nervous  system.  Phosphorus  is  extensively 
used  in  the  manufacture  of  matches,  and  the  fumes  so  common  in 
these  factories  often  produce  the  most  serious  results.  Where 
dental  caries  is  present  extensive  maxillary  necrosis  has  been  re- 
ported by  Brophy  and  others,  as  well  as  great  irritation  of  the  con- 
junctivae and  the  respiratory  mucous  membrane.  In  most  match 
factories  a  strict  rule  is  adopted  requiring  the  employees  to  have 
their  teeth  examined  at  stated  intervals  and,  if  found  necessary, 
put  in  order. 

Poisoning  and  Treatment. — The  effects  of  a  toxic  dose  of  phos- 
phorus are  not  generally  manifested  for  several  hours  after  its  inges- 
tion. The  earliest  symptoms  are  intense  abdominal  pain,  persistent 
vomiting,  thirst,  a  garlicky  taste  in  the  mouth,  restlessness,  and 
prostration.  At  the  end  of  twenty-four  to  thirty-six  hours,  these 
acute  symptoms  gradually  subside,  and  the  hope  is  raised  that  the 
patient  will  surely  recover,  but  frequently  after  a  lapse  of  a  few  hours, 
or  even  two  or  three  days,  the  symptoms  of  the  acute  stage  may 
recur.  In  these  cases  there  is  great  weakness,  the  symptoms  becom- 
ing more  acute,  mucus,  bile,  and  occasionally  disintegrated  blood 
being  contained  in  the  ejected  materials,  which  for  a  time  retain  the 


l88  ALTERATR"Z5    AND    RE5T0RATI\'ES 

odor  and  luminosity  of  phosphorus:  jaundice  develops;  the  liver 
becomes  enlarged  and  painful,  and  the  pulse  grows  very  feeble. 
In  fatal  cases  death  generally  occurs  in  from  a  few  days  to  two  weeks, 
and  is  often  preceded  by  delirium,  conAOilsions,  stupor,  and  coma. 

In  the  treatment  of  pJios phones  poisonings  if  the  drug  has  recently 
been  taken,  emetics  and  purgatives  are  from  the  first  necessary. 
Copper  sulphate  is  considered  the  most  efficient  emetic  as  well  as 
the  best  chemic  antidote,  since  any  excess  forms  with  the  phos- 
phorus the  insoluble  copper  phosphid.  Since  oily  and  fatt}-  sub- 
stances are  active  solvents  for  phosphorus,  all  such  material  should 
be  withheld.     Castor  oil,  then,  as  a  cathartic,  should  not  be  used. 

As  prophylactic  measures  for  the  protection  of  workmen  against 
phosphor-necrosis,  masks  covering  the  mouth  and  nose  have  been 
found  serA-iceable.  as  well  as  the  inhalation  of  the  vapor  of  turpen- 
tine obtained  by  suspending  a  small  A-ial  of  the  fluid  at  the  neck. 
As  has  been  mentioned,  the  teeth  should  be  examined,  especially 
for  caries,  at  stated  intervals,  since  the  presence  of  carious  teeth 
favors  the  tendency  to  maxillar}-  necrosis. 

Therapeutics. — Phosphorus  is  employed  as  a  tonic  to  the  osseous 
tissues  and  in  certain  diseases  of  the  nervous  system  that  are  de- 
pendent upon  exhaustion  rather  than  upon  organic  changes.  In 
neurasthenia  and  chronic  nen-ous  exhaustion  it  is  a  useful  therapeutic 
agent.  Some  cases  of  neuralgia,  particularly  of  the  fifth  nerve  and 
accompanied  by  great  debility,  may  be  relieved  by  full  doses  admin- 
istered every  four  hours  (Butler).  The  drug  has  proved  efficacious 
in  caries,  delayed  union  of  fractures,  osteomalacia,  and  rachitis  (rickets). 
In  functional  impotence  from  sexual  excess,  phosphorus  is  also  a 
valuable  remedy.  The  pill  is  considered  the  most  stable,  and 
therefore  the  best  preparation  in  which  to  administer  the  drug. 

ACmUM  PHOSPHORICUM— U.S.P. 

(Phosphoric  Acid;  Orthophosphoric  Acid;  H3PO4.) 

Under  Phosphorus  it  was  stated  that  when  exposed  to  air  the 
drug  burns,  emitting  white  fumes.  Chemically  considered,  this 
means  that  phosphorus  combines  directly  with  oxj'gen  to  form  phos- 
phorus pentoxid  (P2O5).  This  oxid  is  capable  of  combining  chemi- 
cally with  one,  two,  or  three  molecules  of  water,  forming  thereby 
three  different  acids,  as: 

P2O5  +    H2O  =  H2P2O6  =  2HPO3,  Metaphosphoric  Acid. 

P2O5  +  2H2O  =  H4P2O7,  P>Topho5phoric  Acid. 

P2O5  +  3H2O  =  H6P2O8  =  2H3PO4,  Orthophosphoric  Acid. 


CALCII   PHOSPHAS   PR^CIPITATUS  1 89 

These  three  acids  show  different  reactions,  act  differently  upon 
the  animal  system,  and  form  different  salts.  The  acid  of  phos- 
phorus recognized  by  the  United  States  Pharmacopeia  is  a  colorless 
liquid,  composed  of  85  per  cent,  by  weight  of  absolute  orthophos- 
phoric  acid  and  15  per  cent,  of  water.  It  has  a  strong  acid  taste. 
There  is  an  official  diluted  phosphoric  acid  (Acidum  Phosphoricum 
Dilutum,  U.S.P.,  10  per  cent.)  which  is  usually  employed  when  phos- 
phoric acid  is  indicated,  the  average  dose  of  which  is  30  min.  (2.0 
mils)  in  water. 

Physiologic  Action  and  Therapeutics. — The  action  of  phosphoric 
acid  is  somewhat  like  that  of  the  dilute  mineral  acids,  and  has  no 
relation  to  the  action  of  phosphorus  itself.  In  medicine  the  drug 
is  used  to  allay  thirst  in  diabetes  and  febrile  diseases,  and  to  promote 
gastric  digestion.  The  acid  has  practically  no  use  in  dental  thera- 
peutics, but  is  discussed  here  because  phosphoric  acid  (modified 
somewhat)  is  the  Hquid  combined  with  zinc  oxid  (cement  powder) 
to  make  the  zinc  phosphate  cement,  so  extensively  used  in  dental 
practice.  Nearly  all  of  the  phoshates  found  in  nature  are  ortho- 
phosphates. 

CALCn  PHOSPHAS  PRiECIPITATUS  (Nonofficial) 
(Precipitated  Calcium  Orthophosphate;  Bone  Phosphate;  Ca3(P04)2.) 

Precipitated  calcium  phosphate  occurs  as  a  white,  odorless,  taste- 
less, amorphous  powder;  insoluble  in  cold  water  and  alcohol.  The 
average  dose  is  10  gr.  (0.6  gm.).     There  is  one  official  preparation: 

Syrupus  Calcii  Lactophosphatis,  U.S. P.  (contains  about  3  per 
cent,  of  the  double  soluble  salt).  Dose,  1-4  fl.  dr.  (4.0-15.0 
mils). 

Physiologic  Action  and  Therapeutics.^ — Calcium  phosphate  may 
be  taken  as  the  type  of  the  insoluble  salts  of  calcium,  which  are  so 
frequently  referred  to  in  dental  literature  as  "lime-salts."  Lime  is 
calcium  oxid,  and  as  there  is  no  such  thing  in  chemistry  as  a  salt  of 
an  oxid,  this  term,  lime-salts,  should  be  discarded.  When  taken 
internally,  calcium  phosphate,  for  the  most  part,  resists  absorption 
and  reappears  in  the  stools;  a  small  amount,  however,  is  assimilated, 
and  in  case  of  a  deficiency  of  phosphates  in  the  food  is  appropriated 
by  the  tissues.  Where  the  phosphates  in  the  natural  food-supply 
meet  all  physiologic  requirements,  any  excess  of  the  insoluble  calcium 
salts  is  slowly  excreted  by  the  intestinal  epithelium  and  kidneys. 
Food  ordinarily  contains  more  calcium  phosphate  than  the  body 


I  go  ALTERATIVES   AND    RESTORATIVES 

requires;  it  is,  therefore,  difificult  to  explain  how  the  insoluble  salts  of 
calcium  (phosphate  and  hypophosphite),  administered  as  a  remedy, 
can  be  of  any  physiologic  importance.  Stevens^  states  that  the 
difficulty,  however,  is  no  greater  than  that  which  is  encountered  in 
attempting  to  explain  the  undoubted  efficacy  of  iron  in  chlorosis, 
a  disease  that  is  certainly  not  dependent  upon  a  want  of  iron  salts 
in  the  food.  There  is  no  convincing  evidence  to  show  that  the  in- 
soluble calcium  salts  are  of  much  value  in  themselves  as  therapeu- 
tic agents.  On  theoretical  grounds  they  have  been  prescribed  to 
prevent  the  rapid  decay  of  teeth  during  pregnancy  and  the  nursing 
period,  in  osteomalacia,  and  in  rachitis.  They  seem  to  exert  a 
favorable  influence  on  general  nutrition  in  such  diseases  as  chlorosis, 
anemia,  scrofula,  tuberculosis,  tertiary  syphilis,  and  neurasthenia. 
Calcium  phosphate  may  be  given  in  powders  or  capsules;  the  lacto- 
phosphate,  being  soluble,  may  be  administered  in  the  form  of  the 
official  syrup  or  in  an  emulsion  of  cod-liver  oil. 

As  a  vehicle  for  making  pastes  used  in  capping  pulps,  bleaching 
teeth,  etc.,  the  author  recommends  combining  precipitated  calcium 
phosphate  with  thymol  (2  per  cent.).  This  will  be  explained  in 
Practical  Therapeutics  (see  page  312). 

CALCn  HYPOPHOSPHIS— U.S.P. 

(Calcium  H3rpophosphite ;  Ca(PH202)2-) 

Calcium  hjrpophosphite  occurs  in  colorless,  transparent  crystals, 
or  small  lustrous  scales,  having  a  bitter,  nauseating  taste.  It  is 
soluble  in  about  7  parts  of  water,  insoluble  in  alcohol.  The  average 
dose  is  8  gr.  (0.5  Gm.).  It  enters  as  an  important  constituent  into 
the  following  official  preparation: 

Syrupus  Hypophosphitum,  U.S. P.     Dose,  1-2  fl.  dr.  (4.0-8.0 
mils). 

Physiologic  Action  and  Therapeutics. — The  action  of  hypo- 
phosphites,  of  which  the  calcium  salt  is  a  fair  representative,  is  simi- 
lar to  that  of  calcium  phosphate,  and  they  may  be  employed  as 
therapeutic  agents  in  the  same  class  of  cases  in  which  the  latter  has 
been  recommended.  Calcium  hypophosphite,  being  more  soluble 
in  water,  may  be  assimilated  more  readily,  but  the  same  remarks 
hold  true  of  this  agent  as  were  made  of  calcium  phosphate  in  regard 
to  the  power  of  the  system  to  utilize  the  agent  in  the  constructive 
processes  of  the  body. 

^  Modern  Materia  Medica  and  Therapeutics. 


OLEtIM  MOREHU^  19I 

OLEUM  MORRHU^— U.S.P. 

(Cod-liver  Oil.) 

Cod-liver  oil  is  a  fixed  oil  obtained  from  the  fresh  livers  of  Gladus 
morrhua  and  other  species  of  Gladus.  It  occurs  as  a  thin,  pale  yellow 
liquid,  having  a  characteristic  fishy  odor  and  taste.  It  contains  the 
glycerids  of  olein,  palmitin,  and  stearin,  traces  of  iodin,  bromin, 
chlorin,  phosphorus,  sulphur,  biliary  salts,  and  several  alkaloids 
(leucomains) .  The  average  dose  is  2}4  A-  dr.  (lo.o  mils).  The 
ofl&cial  preparation  is: 

Emulsum  Olei  Morrhuae,  U.S. P.  (50  per  cent.).     Dose,  1-8  fl. 
dr.  (4.0-30.0  mils). 

Physiologic  Action  and  Therapeutics. — From  the  constituents 
of  cod-liver  oil  it  may  readily  be  seen  that  it  is  a  food  rather  than  a 
medicine,  and  is  a  true  restorative.  In  moderate  doses  it  improves 
the  general  nutrition,  increases  the  number  of  red  blood-corpuscles, 
and  favors  the  accumulation  of  fat — a  normal  and  necessary  constitu- 
ent of  the  body.  Fat  is  the  fuel  used  to  supply  energy,  and  the 
most  active  tissues  and  organs  require  the  most  fuel.  Consequently, 
nerves,  muscles,  and  glands  are  more  abundantly  supplied  with  fat 
than  cartilage;  and,  in  cases  of  starvation,  those  structures  demand- 
ing the  greater  supply  must  have  it,  at  the  expense  of  the  less  highly 
organized  and  active  tissues.  This  is  illustrated  in  certain  diseases 
— tuberculosis,  for  example.  Butler^  states  that  the  blood  contains 
about  one-half  of  i  per  cent,  of  fat;  the  muscles,  3  per  cent. ;  the  brain, 
8  per  cent.;  and  the  nerves,  22  per  cent.  This  equilibrium  must  be 
maintained  in  order  that  the  various  cells  of  the  body  may  possess 
sufi&cient  vitaHty  to  physiologically  resist  the  encroachments  of 
disease  and  the  invasion  of  pathogenic  bacteria.  It  is  rather  diffi- 
cult to  digest  and  assimilate  ordinary  fat;  and  this  must  be  done 
before  it  can  enter  the  various  cells  of  the  body  and  act  as  a  food,  and, 
consequently,  be  a  source  of  energy.  Cod-liver  oil  is  more  readily 
absorbed  and  oxidized  than  any  other  fat,  due  to  the  fact  that  it  has 
already  been  prepared  by  the  liver,  and  therefore  partially  elaborated ; 
and  also  to  the  bihary  salts  which  it  contains,  causing  it  to  pass  more 
readily  through  animal  membranes. 

Therapeutics.— Cod-liver  oil  is  a  valuable  restorative  in  all 
emaciating  diseases  resulting  in  anemia.  It  is  especially  indicated 
as  a  nutritive  tonic  in  tuberculosis.  As  a  food  it  may  be  given  in  any 
case  where  fat  is  deficient,  and  therefore  needed  to  supply  energy  to 
the  tissues. 

^  Text-Book  of  Materia  Medica,  Therapeutics  and  Pharmacology. 


192  ALTERATIVES    AND    RESTORATIVES 

POTASSII  lODIDUM— U.S.P. 

(Potassium  lodid;  KI.) 

Potassium  iodid  occurs  as  colorless,  transparent  or  translucent 
crystals  or  as  a  white  granular  powder,  having  a  pungent,  saline 
taste;  soluble  in  0.75  part  of  water,  2.5  parts  of  glycerin,  and  22  parts 
of  alcohol.  The  average  dose  is  3-5  gr,  (0.3  Gm.),  given  well  diluted 
after  meals;  but  in  tertiary  syphilis  often  i  dr.  (4.0  Gm.)  may  be 
given  with  advantage.  The  drug  is  a  constituent  of  Lugol's  solu- 
tion (Liquor  lodi  Compositus,  U.S. P.) 

Physiologic  Action. — Potassium  iodid  is  a  true  alterative  and 
has  a  favorable  action  in  a  variety  of  morbid  conditions.  As  is 
true  with  many  drugs,  potassium  iodid,  given  in  a  single,  moderate 
dose  in  health,  produces  no  noticeable  effects  beyond  a  slight  increase 
in  the  secretion  of  urine  and  some  disturbance  of  the  stomach,  due 
solely  to  its  local  irritant  property.  The  drug  is  rapidly  absorbed 
from  all  parts  of  the  digestive  tract,  and  reappears  in  the  secretions 
in  less  than  fifteen  minutes  after  its  ingestion.  By  far  the  greater 
portion  is  eHminated  through  the  kidneys,  but  small  quantities  es- 
cape in  almost  every  secretion  of  the  body,  as  in  the  saliva,  milk, 
perspiration,  and  even  the  tears.  There  is  little  doubt  that  a 
small  quantity  of  the  drug  is  retained,  for  a  time  at  least,  by  the 
cells  of  the  body  and  that  a  cumulative  action  may  result,  for  its 
continuous  use  is  generally  followed,  sooner  or  later,  by  a  group- of 
symptoms  known  as  iodism.  This  condition  has  previously  been 
mentioned,  and  in  this  instance  results  from  the  local  irritant  effects 
of  free  iodin,  into  which  a  portion  of  the  iodid  appears  to  be  converted. 
There  is  a  remarkable  variance  in  the  susceptibility  of  individuals  to 
the  iodids,  and  idiosyncrasies  are  frequently  encountered.  The 
amount  of  the  drug,  therefore,  required  to  induce  iodism  depends 
upon  the  subject.  Daily  doses  of  from  3^^-^^  oz.  (7.5-15.0  Gm.)  are 
sometimes  well  borne,  and,  on  the  other  hand,  doses  of  from  2-3  gr. 
(0.13-0.2  Gm.)  a  day  may  soon  produce  intense  discomfort. 

Therapeutics. — Potassium  iodid  is  the  one  drug  relied  upon  in 
nearly  all  cases  where  an  alterative  drug  is  indicated.  Its  best  effects 
are  observed  in  tertiary  syphilis,  in  which  stage  of  the  disease  its 
efficacy  is  equal  to  that  of  mercury  in  the  secondary  stage.  The 
initial  dose  should  be  small,  and  the  amount  gradually  increased  until 
improvement  follows  or  symptoms  of  iodism  appear.  It  is  neces- 
sary in  syphiHs  to  continue  the  treatment  for  six  months  or  a  year, 
and  even  longer,  if  permanent  results  are  to  be  expected. 

In  acute  alveolar  abscess  the  author  has  secured  excellent  results 


OTHER   lODIDS  1 93 

in  many  cases  by  the  repeated  internal  administration  of  small  doses 
of  potassium  iodid.  The  nauseating  taste  can  be  masked  by  dissolv- 
ing I  dr.  (4.0  Gm.)  of  the  drug  in  3  fi.  oz.  (90.0  mils)  of  the  com- 
pound syrup  of  sarsaparilla  or  syrup  of  wild  cherry.  One  teaspoon- 
ful  in  water  can  be  given  every  two  hours  until  three  or  four  doses 
have  been  taken. 

Potassium  iodid  has  been  combined  with  expectorants,  and  used 
with  advantage  in  chronic  bronchitis,  when  the  sputum  is  composed  of 
thick,  viscid  mucus.  In  morbid  conditions  of  the  mucous  membrane 
in  chronic  catarrh  the  drug  is  also  useful.  In  actinomycosis^  occurring 
in  man,  the  drug  has  been  used  internally  with  complete  success  as  a 
curative  remedy  in  a  number  of  cases  (Stevens). 

Potassium  iodid  is  highly  efficacious  in  chronic  metallic  poisoning, 
especially  from  lead  and  mercury,  as  it  aids  in  the  elimination  of  the 
metal  by  forming  with  it  in  the  tissues  a  double  soluble  salt. 

OTHER  lODIDS 

The  iodids  of  several  metals  are  used  in  medicine.  Sodium, 
aiimionitmi,  and  strcntiiiiii  iodid  resemble  potassium  iodid  in  their 
action,  and  may  be  used  for  the  same  purposes;  but  they  do  not 
possess  in  the  same  degree  the  virtues  ascribed  to  the  potassium  salt. 
Zinc  iodid  has  different  properties,  due  to  the  zinc  ion,  and  has  been 
elsewhere  discussed. 

HYDRARGYRUM— U.S.P. 

(Mercury;  Quicksilver;  Hg.) 

Mercury  is  a  shining,  silver-white,  heavy  metal,  without  odor  or 
taste.  It  is  a  liquid  at  the  ordinary  temperature,  and  easily  divided 
into  spherical  globules;  but  when  cooled  to  —  40°C.  it  forms  a  ductile, 
malleable  mass.  The  metal  is  insoluble  in  ordinary  solvents,  but 
miscible  with  sacchareous  substances  and  fats,  through  which,  by 
tritutration,  the  globules  may  be  so  finely  divided  as  not  to  be  dis- 
cernible by  the  naked  eye,  in  which  condition  the  drug  is  very  active 
medicinally. 

Mercury  is  largely  used  in  therapeutics  in  the  form  of  its  com- 
pounds, but  there  are  several  ofl&cial  preparations  in  which  metalHc 
mercury  is  incorporated,  after  being  reduced  to  the  finely  divided 
condition.     They  are: 

Hydrargyrum  cum  Creta,  U.S. P.   (contains  38  per  cent,  of 

Mercury).     Dose,  '^i-io  gr.  (0.03-0.6  Gm.). 

Unguentum  Hydrargyri,   U.S. P.   (contains   50  per  cent,  of 

Mercury). 


1 94  ALTEE_\TI\'ES    AXD    RE5T0R.\TI\'ES 

Unguentum  Hydrargyri  Dilutum,  U.S. P.    (Blue  Ointment; 

contains  2>d  per  cent,  of  Mercury;  made  by  mixing  Ointment 

of  Mercur>-,  2;  Petrolatum,  i  part). 

Massa  Hydrarg}-ri,  U.S. P.  (piU  mass  of  Mercun,-;  contains  33 

per  cent,  of  Mercury). 

Oleatum    HydrargjTi,    U.S. P.    (contains    25    per    cent,    of 

Mercur^O  • 

Physiologic  Action. — Zvlercury  is  an  alterative  and  tonic.  Every 
dentist  should  be  thorouglily  familiar  with  the  action  and  effects  of 
this  metal.  When  small  doses  of  an  imirritating  preparation  of  the 
drug  are  given  continuously  for  a  certain  length  of  time,  the  first 
effects  are  observed  in  the  mouth,  for  it  has  a  selective  influence  upon 
the  gums,  jaws,  and  adjacent  structures.  There  is  produced  an  in- 
creased flow  of  saHva,  fetor  of  the  breath,  redness  of  the  gum  margins, 
and  pericementitis,  causing  soreness  of  the  teeth  when  the  jaws  are 
forcibly  brought  together.  If  the  drug  is  not  withdrawn  upon  the 
appearance  of  these  s^inptoms,  the  condition  gradually  grows  worse; 
sahvation  becomes  excessive  (continual  drooling),  the  gums  become 
swollen  and  spongy,  the  teeth  are  loosened  in  their  sockets  and  may 
be  easily  extracted  with  the  fingers,  the  tongue  and  parotid  glands 
enlarge — the  former  sometimes  to  the  extent  that  it  protrudes  from 
the  mouth,  and,  finally,  the  soft  tissues  slough  away,  necrosis  of 
the  bones  sets  in,  and  large  sequestrum  form.  This  group  of  sjTnp- 
toms  is  known  as  ptyalism  or  salivation.  In  these  cases  the  general 
health  is  naturally  affected,  the  patient  becoming  pale  and  losing 
flesh.  Chronic  mercurial  poisoning  occurs  most  frequently  in  work- 
men who  handle  the  metal  or  who  are  exposed  to  its  fumes,  such  as 
makers  of  thermometers,  mirrors,  scientific  instruments,  etc.  It  is 
too  frequently  induced,  however,  by  the  prolonged  use  of  mercury  as 
a  medicine. 

The  drug  is  supposed  to  enter  into  the  composition  of  the  cell  by 
combining  with  the  nucleinic  acid,  forming  mercury  nucleinate.  It 
is  absorbed  gradually,  and  although  every  secretion  of  the  body  con- 
tributes to  its  general  expulsion  from  the  system,  traces  of  the  drug 
have  been  detected  in  the  urine  months  after  its  use  had  been  discon- 
tinued. It  is,  therefore,  one  of  the  slowest  drugs  known  to  be  ehmi- 
nated,  and  its  cumulative  action  is  a  well-estabhshed  fact. 

Treatment  of  Poisoning. — If  the  s}-mptoms  of  ptyaUsm  are  not 
too  pronounced,  discontinuance  of  the  mercury  and  mouth  hygiene 
usually  clear  up  the  symptoms.  In  more  severe  cases,  besides  dis- 
continuing the  use  of  mercury  and  emplo}"ing  prophylactic  measures, 
certain  medicinal  remedies  are  indicated.     The  teetJi  should  not  he 


HYDRARGYRUM  1 95 

extracted,  unless  so  loose  that  they  virtually  fall  out.  Potassium 
chlorate  can  be  dissolved  in  cinnamon  water  (lo  gr.-o.6  Gm.  to  the 
fl.  oz. — 30.0  mils)  and  used  as  a  mouth-wash.  Atropin,  in  medicina 
doses,  may  be  used  twice  daily  to  control  the  flow  of  saliva.  The 
internal  administration  of  potassium  iodid  is  recommended,  as  it 
aids  in  the  elimination  of  mercury  by  forming  with  it  in  the  tissues 
the  double  soluble  salt.  Where  necrosis  of  the  bones  is  evident, 
Cook  and  Mawhinney  recommend  the  local  application  of  a  50  per 
cent,  solution  of  phenolsulphonic  acid.  This  agent  acts  as  a  stimu- 
lant and  hastens  the  formation  of  the  sequestra.  When  the  pain  is 
very  severe,  morphin  may  be  given ;  and  tonics  are  indicated  to  com- 
bat the  exhaustion  and  anemia. 

Therapeutics. — Mercury  and  its  compounds  are  used  in  general 
therapeutics  for  a  variety  of  purposes.  They  act  as  antisyphihtics, 
antiparasitics,  disinfectants,  cathartics,  and  diuretics,  as  well  as 
alteratives  and  tonics.  The  early  methods  of  administering  mercury 
were  by  mouth  and  inunction.  The  oral  method  continues  to  be 
popular,  but  often  causes  troublesome  gastrointestinal  symptoms. 
The  inunction  method  obviates  the  digestive  disturbances,  but  the 
amount  of  the  drug  absorbed  cannot  be  well  controlled  and  it  is 
practically  impossible  to  introduce  an  amount  sufficient  for  syphilis. 
In  recent  years  the  attempt  to  improve  mercurial  therapy  has  been 
mainly  along  two  Unes:  The  perfection  of  the  hypodermic  usage, 
and  the  introduction  of  the  organic  compounds.  The  organic  com- 
pounds of  mercury,  such  as  mercurol  (mercury  with  nucleinic  acid 
from  yeast,  containing  20  per  cent,  of  metallic  mercury),  are  said 
to  be  less  irritating  to  the  gastrointestinal  tract  than  the  inorganic 
salts.  The  use  of  such  agents,  however,  is  rather  experimental,  and 
further  investigation  is  needed  to  determine  their  real  value. 

In  syphilis,  mercurials  and  the  iodids  act  as  specifics.  Sollmann^ 
states  that  the  use  of  the  former,  as  yet,  rests  entirely  upon  an  em- 
pirical basis.  It  is  not  even  known  whether  the  action  of  mercury 
here  is  due  to  specific  toxicity  for  the  germ  of  syphilis  (Spirocheta 
pallida),  or  whether  it  is  due  simply  to  the  general  effects  upon 
metabolism.  The  former  seems  to  be  the  case.  There  is  no  reason 
to  doubt  that  mercury  is  not  only  palliative,  but  curative,  in  the 
secondary  stage  of  syphilis,  congenital  as  well  as  acquired ;  while  it  is 
useless  in  the  first  and  third  stages.  The  first  stage  is  best  treated 
expectantly,  or  now  with  salvarsan,  "go6;"  the  third,  with  iodids. 
Syphilograhers  have  learned  from  sad  experience  that  mercury  can 
be  pushed  much  further  in  the  treatment  of  secondary  syphilis  with- 

^  A  Text-Book  of  Pharmacology. 


196  ALTERATR'ES    AND    RESTOEATR'ES 

out  producing  ptyalism  if  the  mouth  has  first  been  placed  in  a  hy- 
gienic condition,  i.e.,  if  all  irritants  (deposits,  overhanging  fillings, 
etc.)  have  been  removed  by  thorough  prophylactic  treatment. 

The  preparations  most  frequently  prescribed  in  s}'philis  are 
mercury  vdth  chalk  and  compounds,  Hke  the  bichlorid,  biniodid,  and 
protiodid.  As  mentioned  (page  195),  the  organic  compounds  of 
mercury  are  also  used,  and  under  observation.  The  ointments  are 
used  by  inunction. 

In  pediculosis  pubis  (crab-Hce)  the  parasites  are  quickly  destroyed 
by  rubbing  into  the  affected  parts  a  small  amount  of  blue  ointment. 

It  is  the  compounds  of  mercury  that  are  most  valuable  in  dental 
therapeutics.  ^Mercury,  however,  is  used  extensively  in  the  amalga- 
mation of  dental  alloys  in  the  preparation  of  dental  amalgams, 
which  occupy  a  prominent  place  in  dental  practice  as  fiilLing  material 
for  teeth. 

Many  homeopathic  practitioners  object  strenuously  to  the  use 
of  amalgams  for  filling  the  ca\'ities  in  the  teeth  of  their  patients; 
some  go  so  far  as  to  order  all  amalgam  filHngs  removed  and  fillings 
of  other  material  substituted,  in  the  behef  that  the  amalgam  lilhng 
is  gradually  worn  away  and  enough  mercury  is  thus  carried  into 
the  stomach  and  absorbed  to  cause  systemic  disturbances.  The 
idea  is  certainly  far-fetched,  for  while  metaUic  mercury  can  be  sepa- 
rated from  an  amalgam  by  high  compression  or  heat,  it,  nevertheless, 
is  combined  in  the  amalgam  by  a  more  or  less  definite  chemic  union. 
The  author  has  no  positive  proof  to  show  that  mercury  cannot  be 
thus  absorbed;  but  by  close  observation  in  a  long  chnical  experience 
no  constitutional  disturbances  from  this  source  have  been  dis- 
covered. The  same  objections  are  offered  to  the  wearing  of  a  red- 
rubber  denture,  because  mercury  compounds  are  used  as  pigments 
for  coloring  the  rubber.  Surely,  -^dth  the  high  heat  necessary  for 
\ailcanization,  the  mercury  would  combine  -^ith  the  other  elements 
to  form  such  insoluble  (nonabsorbable)  compounds  that  there  would 
be  no  danger  of  systemic  disturbances  from  this  source. 

COMPOUNDS  OF  MERCURY 

Mercury,  like  iron,  forms  two  series  of  compounds  which  are 
not  distinguished  in  their  Latin  titles  as  they  are  in  their  EngUsh 
titles:  mercurous  and  mercuric.  The  former  are  sparingly  soluble 
and  less  active,  while  the  latter  are  more  readily  soluble  in  water 
and  alcohol  and  so  irritant  as  to  be  classed  with  the  poisons.  The 
two  classes    also  diff'er  somewhat   in  regard    to  their   physiologic 


HYDRARGYRI  CHLORIDUM  MITE  I97 

activity.  The  mercurous  compounds,  of  which  the  chlorid  (calomel) 
is  a  type,  powerfully  stimulate  the  glandular  system  and  are  anti- 
septics, alteratives,  and  cathartics.  The  mercuric  compounds,  of 
which  the  chlorid  (corrosive  sublimate)  is  a  type,  are  potent  altera- 
tives, and  powerful  antiseptics  and  disinfectants.  It  is  easy  to 
distinguish  between  the  two  classes  by  the  different  coloration  pro- 
duced with  Hme- water  (Hquor  calcis).  The  former  (ous)  forms  a 
black  precipitate,  the  latter  (ic),  a  yellow. 

HYDRARGYRI  CHLORIDUM  MITE— U.S.P. 
(Mild  Mercurous  Chlorid;  Calomel;  HgCl.) 

Calomel  occurs  as  a  white,  amorphous  powder,  without  odor  or 
taste.  It  is  insoluble  in  all  ordinary  solvents.  The  average  dose 
as  a  laxative  is  23^  gr.  (0.15  gm.) ;  as  an  alterative,  3=-^  gr.  (0.015  gm.). 
It  is  an  important  constituent  of  the  following  official  pill: 

Pilulae  Catharticae  Compositae,  U.S.P.  (each  contains  Calo- 
mel, I  gr. — 0.06  Gm.,  with  Gamboge,  Compound  Extract  of 
Colycinth,  and  Resin  of  Jalap).     Dose,  1-3  pills. 

Physiologic  Action  and  Therapeutics. — Externally  appHed, 
calomel  acts  as  a  stimulant,  antiseptic,  and  desiccant.  Internally 
administered,  it  acts  as  a  cathartic,  diuretic,  and  antisyphihtic. 
Zinc  ointment  to  which  calomel,  10  gr.  (0.6  Gm.)  to  the  ounce  (32.0 
Gm.),  has  been  added  makes  an  excellent  application  in  subacute 
and  chronic  eczema,  and  indolent  venereal  ulcers  are  desiccated  and 
much  improved  by  dusting  them  with  calomel. 

Calomel  acts  as  a  laxative  or  purgative,  according  to  the  way  in 
which  it  is  administered  and  the  susceptibility  of  the  patient.  It  is  a 
rather  peculiar  cathartic  in  that  its  effect  does  not  increase  in  direct 
ratio  with  the  dose,  as  is  true  with  most  cathartic  drugs.  Small 
doses  repeated  every  half -hour  until  i  or  2  gr.  (0.065-0.13  Gm.) 
have  been  taken  generally  operate  more  freely  than  a  dose  of  10  gr. 
(0.6  Gm.)  taken  at  once.  Calomel  produces  a  thorough  evacuation, 
the  stools  being  large  and  loose,  and  usually  charged  with  undecom- 
posed  bile.  Whether  the  drug  increases  the  quantity  of  bile  formed 
in  the  liver  or  simply  hastens  the  flow  through  the  intestines  and 
prevents  its  reabsorption  is  an  unsettled  question.  Experimental 
and  clinical  evidence  point  more  strongly  to  the  latter  assumption. 

In  cases  of  a  sluggish  liver,  the  drug  has  been  used  in  small,  oft- 
repeated  doses  (Ko  gr.-o.oo6  Gm.)  to  advantage.  No  remedy  is  so 
useful  as  calomel  in  the  condition  known  as  '' biliousness y^  which  is 


1 98  ALTERATIVES  AND  RESTORATIVES 

characterized  by  a  thickly  coated  tongue,  fetid  breath,  heavy  urine, 
headache,  and  depression  of  spirits.  In  these  cases  3^  gr.  (o.oi 
Gm.)  may  be  given  every  fifteen  or  twenty  minutes  until  i  gr.  (0.06 
Gm.)  has  been  taken.  If  the  bowels  do  not  move  freely,  it  is  well  to 
follow  the  mercurial  with  a  saline  cathartic  (Epsom  salts  or  a  Seidlitz 
powder) . 

Incompatibles. — Calomel  is  incompatible  with  hydrochloric  add, 
chlorids,  chlorates,  iodids,  bromids,  and  lime-water,  as  well  as  with 
alkaHes,  alkaline  carbonates,  iron,  lead,  and  copper. 

HYDRARGYRI  CHLORIDUM  CORROSIVUM— U.S.P. 
(Mercuric  Chlorid;  Mercury  Bichlorid;  Corrosive  Sublimate;  HgCl2.) 

)i.  Mercuric  chlorid  might  well  have  been  discussed  under  the 
heading  of  Disinfectants,  as  it  is  for  this  purpose  only  that  it  is  used 
in  dental  therapeutics;  but  it  was  left  that  it  might  be  considered 
and  discussed  here  with  the  other  compounds  of  mercury.  It  occurs 
in  the  form  of  colorless,  odorless  crystals  or  a  fine  white  powder, 
having  an  acrid,  metallic  taste.  It  is  soluble  in  13  parts  of  water 
and  in  3  parts  of  alcohol.  The  average  dose  is  }4o  gr-  (0.003  Gm.). 
The  U.S.P.  IX  for  the  first  time  recognizes  an  official  tablet: 

Toxitabellae  Hydrargyri  Chloridi  Corrosivi,  U.S.P.     Exter- 
nally (see  p.  18). 

Physiologic  Action  and  Therapeutics. — Mercuric  chlorid,  called 
usually  bichlorid  or  corrosive  sublimate,'^  acts  as  an  antisyphilitic 
and  tonic,  as  well  as  an  energetic  disinfectant.  It  is  for  the  latter 
action  that  it  is  extensively  employed  in  dental  as  well  as  in  general 
therapeutics. 

The  drug  is  capable  of  destroying  most  bacteria  in  solutions  as 
dilute  as  i  :  20,000,  and  their  spores  in  solutions  of  i  :  10,000.  Certain 
germs,  however,  hke  the  anthrax  bacillus,  are  more  resistant  to  its 
action,  and  stronger  solutions  are  necessary  for  their  complete  de- 
struction. On  the  whole,  it  has  been  the  most  popular  of  the  disinfec- 
tants, and  took  first  rank  with  surgeons  for  use  upon  the  skin  of  the  pa- 
tient and  the  hands  of  the  operator  and /or  irrigating  infected  wounds  and 
cavities.  For  the  patient's  skin  and  the  surgeon's  hands,  solutions  of 
from  I  :  1,000  to  i  1500  have  been  employed;  for  large  wounds  and 
cavities,  i  :  10,000  to  i  :  5,000;  and  for  small  wounds,  i  :  2,000.  The 
drug  is  an  irritant,  and  should  not  be  used,  even  in  dilute  solutions, 
on  serous  membranes.  It  should  be  observed  that  solutions  of 
mercury  bichlorid  are  not  used  to-day  for  irrigating  wounds  to  the 
extent  that  they  were  in  times  past. 


HYDEARGYRI   lODIDUir  RUBROI  1 99 

Mercuric  chlorid  has  three  disadvantages  as  a  disinfectant:  it  is 
extremely  poisonous;  it  is  readily  converted  into  an  inert  compound 
(mercury  albuminate)  in  the  presence  of  albuminous  matter,  and 
it  is  destructive  to  metal  instruments.  This  last  drawback  is  a 
serious  objection  in  dental  therapeutics;  for,  were  it  not  for  this 
fact,  the  drug  would  be  an  ideal  disinfectant  for  instruments.  It 
is  energetic,  soluble,  and  cheap.  Tartaric  or  citric  acid  may  be 
advantageously  combined  with  bichlorid  solutions  to  prevent  the 
mercuric  salt  from  forming  an  insoluble  albuminate  with  the  albumin 
in  the  tissues.  Compressed  tablets  of  mercuric  chlorid,  each  con- 
taining 73^^  gr.  (0.5  Gm.)  with  tartaric  or  citric  acid  are  in  common 
use.  One  of  these  tablets  dissolved  in  a  pint  (480.0  mils)  of  water 
makes  a  i  :  1,000  solution. 

For  sterilizing  infected  dentin  a  i  :  500  solution  is  an  excellent 
remedy.  The  author  suggests  keeping  the  pure  drug  in  papers 
(chartulee)  each  containing  i  gr.  (0.06  Gm.) .  By  so  doing,  an  approxi- 
mate I  :  500  solution  may  be  conveniently  made  at  any  time  by  dis- 
solving the  contents  of  one  paper  in  one  ounce  (30.0  mils)  of  distilled 
water.  Ordinary  water,  containing  traces  of  calcium  salts,  par- 
tially precipitates  the  bichlorid  in  the  form  of  mercuric  oxid.  In 
applying  this  solution  to  the  tooth-structure  with  a  pledget  of  cotton 
and  pliers,  the  latter  should  be  dried  immediately  after  the  appHca- 
tion  on  a  clean,  aseptic  doily,  to  prevent  the  action  of  the  mercury 
upon  the  instrument. 

As  a  parasiticide,  mercury  bichlorid  is  a  valuable  remedy  in 
pediculosis  pubis  and  ring-worm.  In  these  affections,  2-4  gr.  (0.13- 
0.26  Gm.)  to  the  ounce  (30.0  mils)  of  tincture  of  benzoin  make  an 
excellent  appHcation. 

In  syphilis  the  drug  may  be  given  in  pill  or  in  solution.  One- 
twentieth  of  a  grain  (0.003  gm.),  gradually  increased  to  ^-{2  gr. 
(0.005  Gm.),  may  be  given  after  meals. 

HYDRARGYRI  lODIDUM  RUBRUM— U.S.P. 
(Red  Mercuric  lodid;  Mercury  Biniodid;  Hgl2.) 

Mercury  biniodid  occurs  as  a  bright  red,  amorphous  powder, 
without  odor  or  taste.  It  is  practically  insoluble  in  water,  soluble 
in  116  parts  of  alcohol,  and  freely  soluble  in  solutions  of  potassium 
iodid.  The  average  dose  is  }4q  gr.  (0.003  Gm.).  There  is  one 
oflScial  preparation: 

Liquor  Arseni  et  Hydrargyri  lodidi,  U.S.P.  (Donovan's 
Solution;  i  per  cent,  of  each  Iodid).  Dose,  1-5  min.  (0.06-0.3 
mil). 


200  ALTERATIVES  AND  RESTORATIV^ES 

Physiologic  Action  and  Therapeutics. — Mercury  biniodid  re- 
sembles the  bichlorid  in  its  action  and  effects.  In  the  late  secondary 
stage  oj  syphilis  it  may  be  combined  to  advantage  with  potassium 
iodid.  Stevens^  recommends  the  following  formula:  Mercury  bin- 
iodid, I  gr.  (0.06  Gm.);  potassium  iodid,  3  dr.  (12.0  gm.);  water,. 
2  fl.  oz.  (60.0  mils);  compound  syrup  of  sarsaparilla,  sufi&cient  to 
make  4  fl.  oz.  (120.0  mils).  The  dose  is  a  dessertspoonful  in  water 
after  meals. 

Donovan's  solution  is  given  with  benefit  in  medicinal  doses  as 
an  alterative  in  chronic  rheumatism,  tuberculosis,  adenitis,  tertiary 
syphilis,  and  during  convalescence  in  many  exhaustive  diseases. 

HYDRARGYRI  lODIDUM  FLAVUM— U.S.P. 

(Yellow    Mercurous   Iodid;    Mercury   Protiodid;    Green    Mercury 

Iodid;  Hgl.) 

Mercury  protiodid  occurs  as  a  yellow,  amorphous  powder.  It 
is  insoluble  and  without  odor  or  taste.  The  average  dose  is  %  gr. 
(o.oi  Gm.). 

Physiologic  Action  and  Therapeutics. — Mercury  protiodid,  being 
an  ous  compound  is  far  less  irritant  than  the  bichlorid  or  biniodid. 
It  is  considered  the  best  compound  of  mercury  for  use  in  syphilis, 
and  should  be  given  in  pills  or  capsules  to  which  a  little  opium  may 
be  added  in  case  colic  or  diarrhea  is  induced  by  its  ingestion. 

Mercurol  (Mercury  Nucleinate)  is  an  organic  compound  of 
mercury  with  nucleinic  acid  from  yeast.  It  contains  20  per  cent, 
of  metallic  mercury,  and  occurs  as  a  brownish-white  powder ;  soluble 
in  water  (warm  water),  insoluble  in  alcohol.  The  average  dose  is 
I  gr.  (0.06  Gm.). 

The  drug  does  not  coagulate  albumin;  it  has  marked  bactericidal 
power,  and  possesses  the  pharmacologic  action  of  the  soluble  com- 
pounds of  mercury.  It  is  recommended  as  a  local  antiseptic  and  as 
an  antisyphilitic  remedy. 

Sublamin  (Mercuric  Sulphate-ethylenediamin ;  HgS04.2C2H4 
(NH2)2.2H20). — This  compound  is  composed  of  one  molecule  of 
mercuric  sulphate  and  two  molecules  of  ethylenediamin  (a  com- 
pound of  ethylene  and  ammonia).  It  contains  about  44  p6r  cent, 
of  metallic  mercury,  and  occurs  in  white  needles,  odorless,  but  pos- 
sessing a  very  disagreeable  taste;  readily  soluble  in  water  and  in 
10  parts  of  glycerin,  sparingly  soluble  in  alcohol.  It  is  only  used 
externally  as  a  disinfectant,  similar  to  mercuric  chlorid,  over  which 

^  Modern  Materia  Medica  and  Therapeutics. 


ARSENUM  20I 

it  has  the  advantage  of  being  nonirritating,  more  penetrating,  and 
readily  soluble.  A  1:200  solution  is  an  excellent  remedy  for  the 
immediate  sterilization  of  infected  dentin.  The  drug  will  attack  steel 
instruments,  and  the  same  precautions  must  be  observed  here  as 
with  mercuric  chlorid.  It  is  used  in  i  :  1,000  solution  for  hand  dis- 
infection, etc.  By  a  carefully  conducted  series  of  experiments, 
Mawhinney  has  shown  that  the  time  required  for  a  1-200  solution 
to  sterilize  a  broach  was  two  minutes,  and  he  recommends  this 
strength  solution  for  sterilizing  steel  instruments.  The  experience 
of  the  author  with  sublamin  has  proved  it  to  be  a  good  disinfectant, 
but  that  it  attacks  steel  instruments  immersed  in  its  solution  for 
any  length  of  time. 

Incompatibles. — Sublamin  is  incompatible  with  sodium  chlorid 
and  should  not  be  exposed  to  air. 

ARSENUM    (Nonofficial) 
(Arsenic;  As.) 

MetalKc  arsenic  is  not  official,  for  as  such  it  is  not  employed  as 
a  medicine.  The  chief  compound  used  in  therapeutics,  especially 
dental  therapeutics,  is  arsenic  trioxid,  which  has  been  fully  discussed 
as  a  devitalizing  agent  under  Caustics.  Certain  salts  of  arsenous  acid 
(arsenites)  and  arsenic  acid  (arsenates)  are  also  used.  The  following 
compounds  and  preparations  containing  arsenic  in  combination  are 
official : 

Arseni  Trioxidum,  U.S.P.  Dose,  Hq-Mo  gr.  (0.001-0.003 
Gm.). 

Liquor  Acidi  Arsenosi,  U.S.P.  (contains  i  per  cent,  of  Arsenic 
Trioxid  and  5  per  cent,  of  dilute  Hydrochloric  Acid).  Dose, 
1-5  min.  (0.06-0.3  mil). 

LiquorPotassiiArsenitis,  U.S.P.  (Fowler's  Solution;  contains 
the  equivalent  of  i  per  cent,  of  Arsenic  Trioxid  and  3  per  cent, 
of  compound  tincture  of  Lavender).  Dose,  1-5  min.  (0.06-0.3 
mil). 

Sodii  Arsenas,  U.S.P.  Dose,  }i6~H  g^-  (0.004-0.008  Gm.). 
Sodii  Arsenas  Exsiccatus,  U.S.P.  Dose,  >|o-H2  gr-  (0.002 
-0.005  Gm.). 

Liquor  Sodii  Arsenatis,  U.S.P.  (Pearson's  Solution;  contains 
I  per  cent,  of  Exsiccated  Sodium  Arsenate).  Dose,  1-5  min. 
(0.06-0.3  mil). 

Arseni  lodidum,  U.S.P.  Dose,  Ho-Ko  gr.  (0.002-0.006 
bm.). 

Liquor  Arseni  et  Hydrargyri  lodidi,  U.S.P.  (Donovan's  Solu- 
tion).    Dose,  1-5  min.  (0.06-0.3  mil).. 


202  ALTEIL\TWES    AND    RESTOEATIVES 

Physiologic  Action  and  Therapeutics. — The  action  and  uses  of 
arsenic  trioxid  have  been  elsewhere  considered.  Arsenic  in  thera- 
peutic doses  acts  as  an  alterative  by  favoring  nutrition.  Just  how 
the  action  is  brought  about  is  not  well  understood. 

The  drug  is  used  internally  in  a  number  of  quite  diverse  patho- 
logic conditions.  Its  use,  however,  is  purely  empirical.  It  stands 
next  to  iron  in  the  treatment  of  anemia.  Fowler's  solution,  although 
not  curative,  is  the  most  efficient  remedy  in  pernicious  anemia.  In 
neuralgia  dependent  upon  anemia,  arsenic  is  valuable.  The  dose 
should  be  gradually  increased  until  symptoms  of  saturation  appear. 
No  general  tonic,  except  cod-Hver  oil,  is  so  efficacious  as  arsenic  in 
pulmonary  tuberculosis.  The  drug  has  long  been  used  with  reported 
good  results  in  diabetes  mellitus.  It  is  an  excellent  alterative  in 
pyorrhea  alveolaris  associated  with  chronic  rheumatism  or  the  gouty 
diathesis.  The  prolonged  use  of  arsenic  (Koo-z-oO  g^- — 0.0006- 
0.0012  Gm.)  has  been  spoken  of  in  the  highest  terms  in  myocardial 
degeneration  and  angina  pectoris.  In  these  cases  it  may  be  combined 
advantageously  with  strychnin,  and  sometimes  also  with  digitaUs 
(Stevens). 

Individuals  vary  considerably  in  their  susceptibiUty  to  the  action 
of  arsenic,  therefore  it  is  best  to  begin  with  small  doses  of  the  drug 
and  gradually  increase  them  as  occasion  demands.  The  indications 
of  saturation  are  puffiness  under  the  eyes,  especially  noticeable  in  the 
morning,  and  looseness  of  the  bowels  with  cohcky  pains.  For  pills 
arsenic  trioxid  is  generally  selected,  and  for  solutions  the  solution  of 
potassium  arsenite  (Fowler's  solution). 

Incompatibles. — Arsenic  is  incompatible  with  salts  of  iron,  silver, 
copper,  and  ammonium,  magnesium,  calcium,  and  tannic  acid. 

Salvarsan,  "606." — This  is  a  complex  arsenic  compound,  the  hy- 
drochlorid  of  3-diamino-4-dihydroxy-l-arsenobenzene,  corresponding 
to  31.57  per  cent,  of  arsenic.     The  average  dose  is  5  gr.  (0.3  Gm.). 

Salvarsan  is  useful  as  a  specific  remedy  for  syphilis  in  all  stages. 
It  is  claimed  that  the  drug  is  especially  beneficial  in  those  cases 
which  respond  slowly  to  mercury  and  iodids ;  and  that  it  is  useful  in 
all  spirillum  afections,  such  as  malaria.  Neosalvarsan  is  a  similar 
and  later  compound  in  which  the  arsenic  content  of  three  parts  is 
approximately  equal  to  2  parts  of  salvarsan.  It  is  merely  a  soluble 
compound  of  salvarsan  and  its  action  and  uses  are  the  same. 

Contraindications. — Salvarsan  preparations  are  contraindicated 
in  severe  disturbances  of  the  circulatory  organs,  advanced  degenera- 
tions of  the  central  nervous  system,  fetid  bronchitis,  and  cachexias, 


S.AJISAPARILLA ECHINACEA  203 

unless  these  are  a  direct  result  of  s}^liili3 ;  also  in  patients  who  have 
a  pronounced  idiosyncrasy  against  arsenic. 

SARSAPARILLA— U.S.P. 

Sarsaparilla  is  the  root  of  Smilax  officinalis  and  other  species  of 
Smilax,  chmbing  evergreens  growing  in  swampy  forests  of  Mexico 
and  as  far  south  as  the  northern  portion  of  Brazil.  It  contains  sev- 
eral glycosids — parilUn,  saponiyi,  and  sarsa-saponin.  The  average 
dose  is  30  gr.  (2.0  Gm.).     The  follo\\dng  preparations  are  ofl&cial: 

Fluidextractum  Sarsaparillse,  U.S. P.  Dose,  3^-2  fl.  dr.  (2.0- 
8.0  mils). 

Fluidextractum  Sarsaparillae  Compositum,  U.S. P.  Dose, 
3^-2  fl.  dr.  (2.0-8.0  mils). 

Syrupus  Sarsaparillae  Compositus,  U.S. P.  (contains  fluid  ex- 
tract Sarsaparilla,  20;  fluid  extract  Glycyrrhiza,  1.5;  fluid 
extract  Senna,  1.5;  Oil  of  Sassafras,  Oil  of  Anise,  Methyl 
Salicylate,  of  each,  0.02;  Alcohol,  1.9;  Syrup,  to  make  100). 
Dose,  1-4  fl.  dr.  (4.0-15.0  mils). 

Physiologic  Action  and  Therapeutics. — Sarsaparilla  owes  its  phar- 
macologic activity  entirely  to  the  saponins  which  it  contains.  The 
drug  has  been  empirically  used  as  an  alterative  in  syphilis  and  tuber- 
culosis for  centuries,  but  this  view  of  its  action  is  not  accepted  at 
the  present  time,  and  if  it  possesses  any  action  at  all  it  is  simply  that 
of  a  very  mild  nauseant  (Sollmann) .  It  is  chiefly  used  in  the  form  of 
the  compound  syrup  as  a  pleasant  vehicle  for  potassium  iodid,  potas- 
sium bromid,  and  certain  salts  of  mercury. 

ECHINACEA  (Nonofficial) 
(Cone  Flower.) 

Echinacea  is  the  dried  root  of  Echinacea  angustifolia,  a  perennial 
herb  gromng  in  the  central  and  western  portions  of  the  United  States. 
A  fluid  extract  may  be  obtained,  the  dose  of  which  is  from  15-30  min. 
(1.0-2.0  mils) .  The  dose  of  specific  echinacea  (tincture)  is  from  5-30 
min.  (0.3-2 .0  mils) .  Echafolta  is  a  purified,  assayed  form  of  echinacea. 
The  dose  is  the  same.  Externally  or  for  surgical  purposes,  it  is  con- 
sidered greatly  superior  to  any  other  preparation  of  echinacea,  and 
is  prescribed  for  the  same  conditions. 

Echinacea  was  kno\vTi  to  the  Indians  as  a  cure  for  snake  poison. 
The  experiments  with  the  drug  have  been  confined  almost  entirely  to 
the  eclectic  school  of  medicine,  and  remarkable  properties  almost, 
bordering  on  the  miraculous,  are  ascribed  to  it. 


204  ALTERATIVES  AND  RESTORATIVES 

Physiologic  Action. — Applied  to  the  mucous  membrane,  a  warm 
and  tingling  sensation  is  at  once  experienced.  It  is  similar  to  that 
of  aconite,  without  the  sedative  effect.  The  sensation  persists  for 
some  time,  even  though  the  throat  is  gargled,  and  the  agent  entirely 
removed.  The  drug  actively  promotes  the  flow  of  saliva,  and  if 
swallowed,  the  warmth  and  tingling  extend  down  the  esophagus 
to  the  stomach,  but  no  further  unpleasant  influence  is  observed.  In 
a  short  time  diaphoresis  is  observed,  and  the  continuation  of  the 
remedy  stimulates  the  kidneys  to  increased  action.  All  of  the  glandu- 
lar organs  seem  to  respond  to  its  stimulating  influence,  and  their 
functional  activity  is  increased.  The  stomach  is  improved  in  its 
function,  the  appetite  increases,  the  food  is  more  perfectly  digested, 
the  bowels  operate  better,  and  absorption,  assimilation,  and  general 
nutrition  are  materially  improved.  It  encourages  secretion  and 
excretion,  preventing  further  autointoxication,  and  quickly  correct- 
ing the  influence  in  the  system  of  any  that  has  occurred.  It  stimu- 
lates retrograde  metaboHsm,  or  tissue  waste,  more  markedly  than 
any  other  single  remedy  known. 

There  are  but  few  subjective  symptoms  from  large  doses  of  the 
drug.  It  is  apparently  nontoxic,  and,  to  any  unpleasant  extent,  non- 
irritant.  It  has  a  marked  effect  upon  the  nervous  system,  but  its 
action  here  has  not  yet  been  determined  (ElUngwood) . 

Therapeutics. — Hewitt,  CahiU,  and  others  have  recommended 
the  drug  in  dental  therapeutics.  Some  enthusiasts  go  so  far  as  to 
recommend  the  use  of  the  drug  in  almost  every  disease  to  which  the 
body  is  heir. 

The  drug  has  been  used  in  acute  alveolar  abscess  to  prevent  the 
formation  of  pus,  or  after  pus-formation  to  hasten  its  evacuation. 
In  septicemia  (blood-poisoning),  it  is  claimed  to  be  almost  a  specific. 
In  ulcerative  stomatitis^  sore  throat  or  mouth  of  any  character,  the  local 
application  of  echafolta  is  prompt  and  effectual. 

CALCn  SULPHmUM  CRUDUM— U.S.P. 
(Sulphurated  Calcium ;  Crude  Calcium  Sulphid.) 

Sulphurated  calcium  is  a  mixture  containing  at  least  60  per  cent, 
of  calcium  sulphid,  together  with  calcium  sulphate  and  varying  pro- 
portions of  carbon.  It  occurs  as  a  pale  gray  powder,  having  a  nause- 
ating, alkaline  taste  and  a  faint  odor  of  hydrogen  sulphid.  It  is  but 
sHghtly  soluble  in  water  and  insoluble  in  alcohol.  Exposure  to  air 
causes  gradual  decomposition.  The  average  dose  is  i  gr.  (0.06  Gm.), 
in  pills,  tablets,  or  capsules. 


AURI    ET    SODII    CHLORIDUM  20$ 

Physiologic  Action  and  Therapeutics. — The  action  of  calcium 
sulphid  is  not  well  understood.  Its  power  of  preventing  and  arrest- 
ing suppuration  was  first  mentioned  by  Ringer.  It  has  been  found 
especially  useful  in  boils  and  carbuncles  Excellent  results  are  ob- 
tained in  follicular  tonsillitis  and  quinsy  by  giA^ng  small  doses  {}4o 
gr.-0.003  Gm.)  at  short  intervals.  Harlan  recommended  giving  the 
drug  in  doses  of  Ko  gr-  (0.006  Gm.),  at  short  intervals,  in  acute 
alveolar  abscess  and  other  suppurative  conditions,  claiming  that  it  pre- 
vented the  formation  of  pus,  if  given  early  enough,  or,  if  too  late  for 
this,  that  the  agent  hastened  the  evacuation  of  the  pus.  Only  fresh 
preparations  should  be  employed  on  account  of  the  UabiUty  of  the 
drug  to  deteriorate. 

AURI  ET  SODII  CHLORIDUM— U.S.P. 

(Gold  and  Sodium  Chlorid;  AuCla  -fNaCl) 

This  preparation  is  a  mixture  of  equal  parts,  by  weight,  of  dry 
gold  chlorid  and  sodium  chlorid.  It  is  an  orange-yellow  powder, 
deliquescent,  and  of  a  sahne  and  metalHc  taste;  freely  soluble  in 
water.     The  average  dose  is  J^2  gr.  (0.005  Gm.),  in  pill. 

Physiologic  Action  and  Therapeutics. — Gold  and  sodium  chlorid 
is  supposed  to  act  as  an  alterative,  tonic,  and  stimulant  to  the 
digestive  system.  It  has  been  recommended  in  a  number  of  diseases 
where  an  alterative  and  tonic  effect  is  desired,  but  it  is  of  doubtful 
value.  Solutions  of  gold  chlorid  have  been  recommended  by  Ames 
for  cauterizing  exposed  sensitive  cementum,  and  he  claims  that  its 
effect  is  nearly  equal  to  that  of  silver  nitrate  without  the  discolo- 
ration. 

DIGESTANTS 

The  mouth  and  the  stomach  are  intimately  connected  and  closely 
related;  so  much  so  that  pathologic  conditions  in  one  often  predis- 
pose to  disease  in  the  other.  It  is  therefore  important  that  the 
dentist  be  familiar  with  the  action  and  uses  of  certain  agents  which 
materially  assist  in  the  digestion  of  food.  Those  not  discussed  under 
other  headings  will  here  be  considered.     They  are: 

Pepsin.  Malt. 

Pancreatin.  Papain. 

PEPSINUM— U.S.P. 

(Pepsin.) 

Pepsin  is  a  proteolytic  ferment  or  enzyme  obtained  from  the 
glandular  layer  of  fresh  stomachs  from  healthy  pigs.     It  occurs  as  a 


2o6  DIGE5TANTS 

yellowish.- white,  amorphous  powder,  or  in  thin,  pale  yellow  scales, 
ha%dng  a  faint  odor  and  a  sHghtly  acidulous  or  saline  taste.  It  is 
soluble  in  50  parts  of  water,  more  so  in  water  acidulated  with  hydro- 
chloric acid,  and  insoluble  in  alcohol.  The  Pharmacopeia  of  the 
United  States  requires  the  drug  to  be  capable  of  digesting  not  less 
than  3,000  times  its  weight  of  freshly  coagulated  and  disintegrated 
egg  albumin.     The  average  dose  is  8  gr.  (0.5  Gm.) 

Physiologic  Action  and  Therapeutics. — Pepsin  is  an  excellent 
digestive,  being  a  normal  constituent  of  the  gastric  juice,  and  in  the 
presence  of  hydrochloric  acid  (a  natural  acid  of  the  stomach)  it 
digests  the  proteid  elements  of  the  food,  converting  these  insoluble 
substances  into  albumoses,  and  finally  into  soluble  peptones.  The 
drug  is  given  in  cases  where  there  is  a  lessened  secretion  of  gastric 
juice,  as  in  atonic  dyspepsia,  cancer  of  the  stomach,  and  gastric  ulcer. 
Many  organic  acids,  alcohol,  and  alkalies  impair  the  proteolytic 
action  of  pepsin. 

PAKCREATINTJM— U.S.P. 

(Pancreatin.) 

Pancreatin  is  a  mixture  of  enzymes  naturally  existing  in  the 
pancreas  of  warm-blooded  animals,  and  is  obtained  from  the  fresh 
pancreas  of  the  hog  or  the  ox.  It  consists  principally  of  amylopsin, 
trypsin,  and  steapsin.  To  be  up  to  the  ofticial  standard  it  should 
be  capable  of  converting  not  less  than  25  times  its  weight  of  starch 
into  water-soluble  substance  (dextrose).  It  occurs  as  a  cream- 
colored  powder,  slowly  but  not  completely  soluble  in  water,  insoluble 
in  alcohol.     The  average  dose  is  8  gr.  (0.5  Gm.). 

Physiologic  Action  and  Therapeutics. — The  action  of  pancreatin 
is  due  to  the  active  erLZ}Tnes  which  it  contains,  of  which  tr}^sin 
digests  proteids,  amylopsin  acts  upon  starches,  and  steapsin  emulsi- 
fies fats  and  oils,  resolving  them  into  fatty  acids  and  glycerin.  The 
drug,  like  pepsin,  is  used  as  an  artificial  digestant  in  certain  disorders 
of  the  stomach  wherein  digestion  is  impaired. 

MALTUM— U.S.P. 
(Malt.) 

Malt  is  the  grain  of  one  or  more  varieties  of  Eordeum  sativum 
(barley),  partially  germinated  artificially,  and  then  dried.  The 
extract  is  official : 


DIASTASUM — PAPAYOTIN  207 

Extractum  Malti,  U.S. P.     Dose,  4  fl.  dr.  (15.0  mils). 
Fluidextractum  Malti,   N.F.    (contains   25   per   cent.   vol. 
alcohol).     Dose,  2  fl.  dr.  (8.0  nuls). 

If  the  extract  of  malt  is  prepared  according  to  the  process  of  the 
United  States  Pharmacopeia,  the  fresh  preparation  will  contain 
diastase,  an  efficient  ferment  and  capable  of  converting  starch  into 
dextrose.  The  diastatic  power  rapidly  deteriorates  on  keeping. 
The  extracts  of  malt  are  extensively  used  as  digestants  and  as  general 
tonics,  but  their  value  is  more  or  less  questionable,  probably  on 
account  of  the  difficulty  of  obtaining  the  preparation  fresh  and 
properly  prepared .     Heat  above  57°C.  (i35°F.)  destroys  the  diastase. 

DIASTASUM— U.S. P. 

(Diastase.) 

Diastase  is  a  mixture  containing  amylolytic  enzymes  obtained 
from  an  infusion  of  malt.  It  occurs  as  a  yellowish-white,  amorphous 
powder,  or  in  translucent  scales;  odorless  and  tasteless.  It  has  the 
power  of  converting  not  less  than  50  times  its  weight  of  potato 
starch  into  soluble  carbohydrates  (dextrin  and  maltose).  It  should 
be  kept  in  weU-closed  containers,  protected  from  light,  heat  and 
moisture.  Diastase  is  soluble  in  water,  the  solutions  being  more 
or  less  turbid;  almost  insoluble  ia  alcohol.  The  drug  is  used  as  a 
digestant  and  general  tonic.     The  average  dose  is  8  gr.  (0.5  Gm.). 

PAPAYOTIN  (Nonofficial) 
(Papain;  Papoid;  Caroid.) 

Papain  is  a  natural  albuminous  ferment  obtained  from  Carica 
papaya,  the  papaw  tree,  growing  in  the  tropics.  It  occurs  as  a 
grayish- white,  amorphous  powder,  without  odor  or  taste.  It  is 
soluble  in  water  and  glycerin,  but  insoluble  in  alcohol  and  ether. 
The  average  dose  is  8  gr.  (0.5  Gm.). 

Physiologic  Action  and  Therapeutics. — It  is  claimed  that  papain 
will  convert  proteids  into  peptones,  starch  into  maltose,  and  emulsify 
fats;  and  that  although  it  will  act  in  neutral  or  acid  solutions,  it  is 
most  active  in  solutions  of  an  alkahne  reaction  (Stevens).  Harlan 
introduced  the  drug  in  dental  therapeutics  for  digesting  pulp  tissue 
after  devitahzation.  He  suggested  making  a  paste  wdth  glycerin, 
acidulating  with  i  or  2  min.  of  a  i :  500  solution  of  hydrochloric 
acid.  The  pulp  was  devitaHzed  in  the  usual  V\'ay,  and  this  paste 
sealed  in  contact  with  the  dead  tissue  for  one  or  two  weeks,  when 


2o8  CATHARTICS 

the  tissue  was  supposed  to  be  liquefied.  Clinical  experience  with 
the  drug  in  dental,  as  well  as  in  general  therapeutics,  proves  it  of 
doubtful  value. 

CATHARTICS 

Cathartics  have  been  elsewhere  defined  as  agents  which  produce 
evacuation  of  the  bowels.  The  drugs  having  this  property  are  classi- 
fied according  to  the  intensity  of  their  action  and  the  character 
of  the  stool  thus  produced.  Those  that  are  mild  in  action  and  pro- 
duce a  nearly  normal  stool  are  called  laxatives.  Those  more  power- 
ful, usually  producing  more  copious  stools,  are  termed  purgatives. 
Those  which  produce  a  watery  evacuation  of  the  bowels  are  called 
hydragogues.  Those  which  gripe,  having  a  violent  action,  and  in 
overdoses  produce  symptoms  of  acute  enteritis,  are  termed  drastics. 

The  chief  laxatives  are: 


Cascara  Sagrada. 

Figs. 

Tamarind. 

Prunes. 

Manna. 

Honey. 

ef  purgatives  are: 

Aloes. 

Calomel.* 

Senna. 

Blue  Mass.* 

Castor  Oil. 

Sulphur. 

Rhubarb. 

Phenolphthalein, 

The  principal  hydragogues  are: 

Magnesium  Sulphate.  Sodium  Phosphate. 

Sodium  Sulphate.  Magnesium  Citrate. 

Potassium  and  Sodium  Tartrate. 

The  main  drastics  are: 


Croton  Oil. 

Gamboge. 

Colocynth. 

Jalap. 

Podophyllum. 

CASCARA  SAGRADA— U.S.P. 

(Rhamnus  Purshiana,   U.S.P.  VIII;  Chittem  Bark.) 

Cascara  sagrada  is  the  dried  bark  of  Rhamnus  Purshiana,  a  small 
tree  growing  along  the  Pacific  coast  of  North  America.  It  contains 
a  crystalline  glucosid,  purshianin,  that  is  several  times  as  active 
as  the  crude  drug.  The  average  dose  of  cascara  sagrada  bark  is 
15    gr  (i.o  Gm.).     The  following  preparations  are  ofl&cial: 


TAMARINDUS FICUS  209 

Fluidextractum  Cascara  Sagrada,  U.S. P.     Dose,  10-30  min. 

(0.6-2.0  mils). 

Fluidextractum  Cascara  Sagrada  Aromaticum,  U.S. P.    Dose, 

10-30  min.  (0.6-2.0  mils). 

Extractum  Cascara  Sagrada,  U.S. P.     Dose,  2-8  gr.   (0.13- 

0.5  Gm.). 

Physiologic  Action  and  Therapeutics. — Cascara  sagrada  is  a 
peculiarly  efficient  laxative.  Its  action  is  somewhat  slow  and  is 
seldom  accompanied  with  irritation  or  unpleasant  symptoms.  It  is 
used  exclusively  as  a  tonic  laxative,  and  in  habitual  constipation  it 
is  a  reliable  remedy.  The  drug  possesses  a  distinct  advantage  over 
many  cathartics  in  not  readily  losing  its  effect  when  frequently  taken ; 
in  fact,  in  most  cases  the  dose  can  be  diminished  gradually,  and 
this  is  usually  the  most  satisfactory  way  of  administering  the  remedy. 
On  account  of  the  unpleasant  bitter  taste  the  aromatic  fluid  extract 
is  the  best  preparation  to  use. 

TAMARINDUS  (Nonofficial) 
(Tamarind.) 

Tamarind  is  the  preserved  pulp  of  the  fruit  of  Tamarindus  indica, 
a  large  tree  indigenous  to  Africa  and  cultivated  in  the  West  Indies. 
It  is  a  gentle  laxative  about  equal  in  power  to  the  fig  and  prune. 
Its  action  is  due  chiefly  to  the  potassium  salts  of  tartaric,  citric, 
malic,  and  acetic  acids,  of  which  it  contains  from  8-12  per  cent. 
The  average  dose  is  4  dr.  (16.0  Gm.).  It  is  a  constituent  of  the 
formerly  official  confection  of  senna. 

MANNA— U.S.P. 

Manna  is  a  concrete  saccharine  exudation  from  Fraxinus  Ornus,  a 
small  native  tree  of  Sicily  and  other  Mediterranean  islands.  Its 
chief  constituent  is  mannite  (50-80  per  cent.)  a  sweet  crystalline 
principle,  soluble  in  water.  It  acts  as  a  mild  laxative  in  doses  of 
1-2  oz.  (32.0-64.0  Gm.).  It  is  usually  given  in  combination  with 
other  cathartics,  and  is  a  constituent  of  the  official  compound 
infusion  of  senna. 

FICUS  (Nonofficial) 

(Fig.) 

Fig  is  the  dried  fruit  of  Ficus  Carica,  a  native  tree  of  the  shores  of 
the  Levant,  but  cultivated  in  tropical  countries.  It  contains  about 
62  per  cent,  of  grape-sugar,  also  gum,  fat,  etc.     It  acts  as  a  demulcent 


2IO  CATHARTICS 

and  laxative,  and  is  a  constituent  of  the  formerly  official  confection 
of  senna.  Figs  are  chiefly  used  as  an  article  of  diet  in  habitual 
constipation. 

PRUNUM  (Nonofficial) 
(Prune.) 

Prune  is  the  dried  fruit  of  Prunus  Domestica,  the  plum  tree, 
indigenous  to  Western  Asia,  but  cultivated  in  most  temperate 
countries.  It  contains  sugar,  pectin,  albumin,  malic  acid,  and  salts. 
Prunes  are  laxative  and  nutritious,  and  are  freely  used  as  food  and 
sweetmeat.  Stewed  prunes  are  an  excellent  remedy  for  constipation 
in  children.  They  are  a  constituent  of  the  formerly  official  confection 
of  senna. 

MEL— U.S.P. 

(Honey.) 

Honey  is  a  saccharine  secretion  deposited  in  the  honey-comb  by 
Apis  Mellifica,  the  honey-bee.  It  is  a  strong  aqueous  solution  of 
several  sugars  (cane-  and  grape-sugar,  levulose)  with  wax  pollen, 
coloring  and  odorous  matters,  etc.  Honey  is  often  adulterated 
with  starch  and  glucose.  The  dose  is  indefinite.  Clarified  honey 
is  official  (mel  depuratum,  U.S. P.),  and  is  an  ingredient  of  con- 
fection of  senna,  U.S. P.  VIII,  and  of  the  official  honey  of  rose  (mel 
rosas,  U.S. P.).  Honey  is  a  laxative,  nutritive,  and  emollient.  It 
is  used  chiefly  as  an  emollient  in  diseases  of  the  throat  to  reheve 
dryness,  pain,  cough,  and  dysphagia,  and  also  as  a  pleasant  vehicle 
for  certain  nauseous  drugs.  Honey  of  rose  is  slightly  astringent, 
and  is  used  in  gargles,  sprays,  or  washes  for  inflammatory  and  ulcer- 
ating conditions  of  the  mucous  membrane  of  the  mouth,  throat,  and 
nasal  passages.  The  wax  obtained  from  the  honey-comb  is  a  useful 
material  in  dental  practice. 

ALOE— U.S.P. 

(Aloes.) 

Aloes  is  the  inspissated  juice  obtained  from  the  leaves  of  several 
species  of  genus  Aloe,  a  familiar  example  of  which  is  the  American 
century  plant.  It  grows  abundantly  in  nearly  all  hot,  dry  countries. 
Two  varieties  were  formerly  recognized  by  the  United  States  Phar- 
macopeia (1890):  Barbadoes  aloes  {Aloe  barbadensis) ,  obtained  from 
Aloe  vera,  and  Socotrine  aloes  (Aloe  socotrina),  obtained  from  Aloe 


SENNA  211 

perryi.  The  chief  constituent  is  aloin,  also  official,  a  neutral  crys- 
talline principle,  and  from  which  is  obtained  emodin,  a  glucosid  to 
which  the  purgative  property  of  the  drug  is  doubtless  due.  Emodin 
is  also  found  in  senna  and  rhubarb.  The  average  dose  of  aloes  is 
4  gr.  (0.25  Gm.).     The  following  preparations  are  official: 

Aloninnm,  U.S. P.     Dose,  3-1-2  gr.  (0.016-0. 13  Gnu). 
Tinctura  Aloes,   U.S. P.     Dose,   3^-2  fl.  dr.   (2.0-8.0  mils). 
Pilulas  Aloes,  U.S.P.  (contains  about  2  gr.-0.13  Gm.).    Dose, 
1-5  pills. 

Pilulae  Rhei  Compositse,  U.S.P.  (contains  Aloes,  i3^  gr.-o.i 
Gm.;  Rhubarb,  2  gr.-0.13  Gm.;  Myrrh  and  Oil  of  Peppermint). 
Dose,  1-5  pills. 

The  drug  enters  into  other  official  preparations,  as  compound 
extract  of  colocjTith,  compound  tincture  of  benzoin,  compound 
cathartic  pills,  and  other  vegetable  cathartic  pills. 

Physiologic  Action  and  Therapeutics. — .Aloes  is  a  rather  slowly 
acting  but  effective  purgative.  It  will  be  noticed  from  the  list  of 
preparations  that  aloes  is  rarely  used  singly  as  a  cathartic.  In 
simple,  persistent  constipation,  it  may  be  combined  advantageously 
with  other  drugs,  nux  vomica,  ipecac,  rhubarb,  or  podophyUum. 
Pills  of  aloes  and  iron,  formerly  official,  are  often  given  with  benefit 
in  chlorosis  with  constipation.  The  liquid  preparations  have  a  dis- 
agreeable taste  which  is  difficult  to  mask  and  are  rarely  given.  The 
pill  is  the  popular  form  of  administering  the  drug. 

SENTTA— U.S.P. 

Senna  is  the  leaflets  of  Cassia  acutifolia  and  Cassia  angustiiolia, 
smaU  shrubs  growing,  respectively,  in  Africa  and  India.  It  contains 
chiefly  an  active  acid  glucosid,  cathartin  or  cathartinic  acid,  also 
emodin.  The  average  dose  is  i  dr.  r4.oGm/'.  The  following  prepa- 
rations are  official: 

Fluidextractum   Sennie,    U.S.P.     Dose.   1—2   fl.   dr.    (4.0-S.o 

mils). 

Syrupus  Senme,  U.S.P.  (25  per  cent.}.     Dose.  1-4  fl.  dr.  (4.0- 

15.0  mils.). 

Infusum  Sennae  Compositinn,  U.S.P.  (Black  Draft:  Senna,  6; 

Fennel,  2;  Manna,  12;  Epsom  Salts,  12).     Dose,  1-4  fl.  oz. 

(30.0-120.0  mils). 

Confectio  Sennae,  U.S.P.,  \lli  (10  per  cent.,  with  Cassia 

Fistula,  Tamarind,  Prune,  Fig,  Sugar,  and  Coriander  Oil). 

Dose,  1-2  dr.  (4.0-8.0  Gm.). 

Pulvis    Glyc^Trhizs    ComposiDJS,    U.S.P.    (i3    per   cent,    of 


212  CATHARTICS 

Senna,    with   Licorice,    Sulphur,    Sugar,    and   Fennel    Oil). 
Dose,  H~2  dr.  (2.0-8.0  Gm.). 

Syrupus  Sennae,  U.S.P,  (from  Fluidextract) .     Dose,  1  fl.  dr. 
(4.0  mUs). 

Extract  of  senna  (1.5  per  cent.)  is  a  constituent  of  compound 
syrup  of  sarsaparilla. 

Physiologic  Action  and  Therapeutics. — Senna  acts  energetic- 
ally as  a  purgative.  Its  action  is  more  irritating  than  that  of  rhu- 
barb and  more  prompt  and  powerful  than  that  of  aloes.  It  is  one 
of  the  best  vegetable  purgatives,  and  its  effect  is  certain  and  reliable 
in  simple,  acute  constipation.  In  habitual  costiveness,  compound 
licorice  powder  is  a  popular  household  remedy.  It  is  given  at  bed- 
time in  about  a  teaspoonful  dose,  governed  by  the  age  of  the  patient. 

OLEUM  RICmi— U.S.P. 

(Castor  Oil.) 

Castor  oil  is  a  fixed  oil  expressed  from  the  seed  of  Ricinus  com- 
munis, a  plant  indigenous  to  India,  but  cultivated  in  many  other 
temperate  countries.  It  occurs  as  a  pale  yellow,  viscid  oil,  having 
a  faint  odor  and  a  slightly  acrid,  offensive  taste.  It  is  freely  soluble 
in  alcohol.  It  contains  the  glycerid  of  ricinoleic  acid,  called  ricin- 
olein,  and  to  which  the  purgative  property  of  the  drug  is  due.  The 
dose  of  castor  oil  is  from  i  fl.  dr.-i  fl.  oz.  (4.0-30.0  mils),  governed  by 
the  age  of  the  patient. 

Physiologic  Action  and  Therapeutics.^ — Castor  oil  is  a  mild,  but 
thorough  purgative.  Stevens^  states  that  while  its  fate  in  the  body 
has  not  been  definitely  determined,  it  is  probable  that  it  escapes 
from  the  stomach  unchanged,  and  that  in  the  presence  of  the  alka- 
hne  juices  of  the  intestines  saponification  occurs  with  the  liberation 
of  ricinoleic  acid,  which  is  subsequently  converted  into  ricinoleates. 
The  latter  induce  catharsis  by  stimulating  the  muscular  coat  of  the 
bowel,  and  are  probably  absorbed,  since  the  oil  is  known  to  impart  its 
purgative  properties  to  the  milk  when  given  to  nursing  women. 

Castor  oil  has  long  been  a  household  remedy  to  remove  irritant 
material  from  the  bowel  in  the  beginning  of  acute  inflammatory 
diarrhea,  especially  in  children.  It  is  not  a  suitable  remedy  for 
habitual  constipation,  as  is  generally  supposed  by  the  laity.  The 
drug  is  a  desirable  constituent  of  many  lotions,  used  on  the  scalp 
for  dandruff,  etc.,  owing  to  its  solubility  in  alcohol. 

Patrick,  Moyer,  and  other  neurologists  highly  recommend  large 

^  Modern  Materia  Medica  and  Therapeutics. 


RHEUM  213 

doses  of  castor  oil  in  tic  douloureux.  Smaller  doses  are  first  admin- 
istered, and  gradually  increased  until  large  quantities  may  be  taken 
daily  without  inducing  catharsis. 

The  main  objection  to  castor  oil  as  a  therapeutic  agent  is  its 
disagreeable  taste.  Many  substances  have  been  suggested  to  over- 
come this  objection,  among  which  may  be  mentioned  the  oils  of 
peppermint,  gaultheria,  and  cinnamon,  A  pleasant  combination 
follows : 

Castor  Oil,  8  oz.  (240.0  mils);  Oil  of  Peppermint,  5  min.  (0.3 
mil);  Saccharin,  2  gr.  (0.13  Gm.);  and  Alcohol,  i  dr.  (4.0 
mils).  The  Oil  of  Peppermint  and  Saccharin  should  first  be 
dissolved  in  Alcohol  and  then  added  to  the  Castor  Oil.  The 
usual  dose  may  be  given. 

Castor  Oil  may  also  be  given  in  flexible  capsules. 

RHEUM— U.S.P. 
(Rhubarb.) 

Rhubarb  is  the  root  of  Rheum  officinale,  a  perennial  herb  resem- 
bHng  garden  rhubarb,  but  of  larger  growth,  and  a  native  of  China, 
Thibet,  and  other  Asiatic  countries.  It  contains  chrysophanic  acid, 
emodin,  tannic  acid,  and  several  resinous  principles.  It  is  to  emodin 
and  possibly  some  of  the  resinous  principles  that  rhubarb  owes  its 
purgative  properties,  for  chrysophanic  acid  has  no  purgative  action 
and  tannic  acid  is  an  astringent.  The  average  dose  of  rhubarb  is 
15  gr.  (i.o  Gm.).     The  following  preparations  are  official: 

Tinctura  Rhei,  U.S. P.  (10  per  cent.,  with  Cardamom). 
Dose,  1-2  fl.  dr.  (4.0-8.0  mils). 

Tinctura  Rhei  Aromatica,  U.S. P.  (20  per  cent.,  with  Aromat- 
ics).     Dose,  }'i-i  fl.  dr.  (2.0-4.0  mils). 

Fluidextractum  Rhei,  U.S. P.     Dose,  10-30  min.  (0.6-2.0  mils). 
Extractum  Rhei,  U.S. P.    Dose,  5-10  gr.  (0.3-0.6  Gm.). 
Syrupus  Rhei,  U.S.P.  (10  per  cent,  of  the  fluid  extract). 
Dose,  1-6  fl.  dr.  (4.0-22.5  mils). 

Syrupus  Rhei  Aromaticus,  U.S.P.  (15  per  cent,  of  aromatic 
tincture  and  spiced  syrup  of  Rhubarb).  Dose,  1-6  fl.  dr. 
(4.0-22.5  mils). 

Pulvis  Rhei  Compositus,  U.S.P.    (Gregory's  Powder;  Rhu- 
barb, 25;  Magnesia,  65;  Ginger,  10).     Dose,  20-60  gr.  (1.3-4.0 
Gm.). 
Pilulae  Rhei  Compositae,  U.S.P.     Dose,  1-5  pills. 

Physiologic  Action  and  Therapeutics.^Rhubarb  acts,  in  appro- 
priate doses,  as  a  purgative  and  stomachic.  As  a  secondary  effect, 
however,  it  frequently  causes  constipation,  due  to  the  tannic  acid  it 


214  CATHARTICS 

contains.  Doses  of  from  1-3  gr.  (0.06-0.2  Gm.)  often  produce  no 
cathartic  action,  but  its  effect  upon  the  stomach  is  that  of  a  mild 
astringent  and  tonic. 

As  an  agent  for  removing  irritant  material  from  the  bowel  in  the 
beginning  of  acute  inflammatory  diarrhea,  especially  in  children, 
rhubarb  is  highly  efficient.  To  check  diarrhea  in  cholera  morbus 
the  following  has  been  a  popular  remedy:  tincture  of  rhubarb,  tinc- 
ture of  capsicum,  tincture  of  opium,  spirit  of  camphor,  and  spirit  of 
peppermint — an  equal  quantity  of  each.  The  dose  is  from  15-30 
min.  (1.0-2.0  mils),  in  water. 

SULPHUR 

(S.) 

The  element  sulphur  is  recognized  by  the  United  States  Pharma- 
copeia in  three  forms: 

Sulphur  Sublimatum. — ^U.S.P.  (Subhmed  Sulphur;  Flowers  of 
Sulphur). — This  occurs  as  a  fine  yellow  powder,  having  a  sHghtly 
characteristic  odor  and  a  faintly  acid  taste.  It  is  insoluble  in  water, 
partially  soluble  in  absolute  alcohol,  ether,  and  chloroform.  The 
average  dose  is  i  dr.  (4.0  Gm.). 

Sulphur  Lotum — ^U.S.P.  (Washed  Sulphur) . — This  form  of  sul- 
phur is  prepared  by  digesting  sublimed  sulphur  for  three  days  in 
weak  ammonia  water,  and  then  washing.  It  enters  into  two  official 
preparations: 

Unguentum  Siilphuris,  U.S. P.  (15  per  cent.). 

Pulvis  Glycyrrhizae  Compositus,  U.S. P.  (8  per  cent.)     Also, 

Unguentum  Sulphuris  Compositum,  N.F. 

Sulphur  Praecipitatum — ^U.S.P.  (Precipitated  Sulphur;  Milk  of 
Sulphur) . — This  is  a  fine,  almost  white  powder,  without  odor  or  taste. 
It  is  prepared  by  precipitation  from  calcium  sulphid  solutions  with 
diluted  hydrochloric  acid.     The  average  dose  is  i  dr.  (4.0  Gm.). 

Physiologic  Action  and  Therapeutics. — Sulphur  acts  locally  as  a 
stimulant  and  parasiticide.  Internally,  it  acts  as  a  mild  purgative. 
As  a  stimulating  remedy  it  has  been  recommended  in  pyorrhea 
alveolaris,  but  its  use  is  of  doubtful  value.  It  is  a  reliable  remedy, 
however,  in  parasitic  diseases,  like  scabies  (itch)  and  ring-worm. 
The  ointment  may  be  employed.  The  drug  may  be  given  internally, 
mixed  with  honey  or  molasses,  as  a  laxative.  When  sulphur  is  burned 
in  the  air,  sulphur  dioxid  (SO2)  is  formed.  This  acid-forming  oxid 
(anhydrid)  unites  with  water  to  form  sulphurous  acid  (H2SO3), 
which  latter  product  is  a  potent  disinfectant  and  bleaching  agent. 


PHENOLPHTHALEINITM MAGNESH    SULPHAS  21 5 

Kirk  recommends  a  mixture  of  boric  acid-  and  sodium  sulphite  as  a 
bleaching  agent  for  tooth-structure.  The  mixture  should  be  placed 
in  the  cavity  dry,  then  moistened  and  hermetically  sealed.  A  re- 
action is  brought  about  whereby  sulphurous  acid  is  formed. 

PHENOLPHTHALEmUM— U.S.P. 

(Phenolphthalein ;    C20H14O4.) 

Phenolphthalein  is  a  dibasic  phenol  derivative.  It  occurs  as  a 
white  or  faintly  yellowish- white,  crystalline  powder;  without  odor 
or  taste;  permanent  in  the  air.  Almost  insoluble  in  water;  soluble 
in  13  parts  of  alcohol,  and  in  70  parts  of  ether  at  25°C.  It  is  dis- 
solved by  solutions  of  the  alkali  hydroxids  and  carbonates  with  a 
red  color.  The  solutions  are  decolorized  by  the  addition  of  acids  in 
excess.  Owing  to  this  peculiar  property  the  agent  is  used  as  an 
indicator  in  volumetric  assaying  and  in  quantitative  analysis.  The 
drug  has  been  recommended  as  a  purgative.  The  average  dose  is 
2}i  gr.  (0.15  Gm.). 

MAGNESn  SULPHAS— U.S.P. 

(Magnesium  Sulphate;  Epsom  Salt;  MgS04.7H20.) 

Magnesium  sulphate  occurs  in  small,  colorless,  rhombic  prisms 
or  acicular  crystals,  without  odor,  and  having  a  cooling,  saline,  un- 
pleasant, and  bitter  taste;  soluble  in  1.5  parts  of  water,  and  insoluble 
in  alcohol.  The  average  dose  is  4  dr.  (16.0  Gm.).  The  drug  enters 
into  one  official  preparation : 

Infusum  Sennae  Compositum,  U.S. P.  Dose,  4-6  fl.  oz. 
120. 0-180.0  mils). 

Magnesii  Siilphas  Effervescens,  U.S. P.  \T;II  (contains  Magne- 
sium Sulphate,  500;  Sodium  Bicarbonate,  403;  Tartaric  Acid, 
211;  Citric  Acid,  136).     Dose,  1-8  dr.  (4.0-32.0  Gm.). 

Physiologic  Action. — Magnesium  sulphate  is  a  typical  represen- 
tative of  the  class  of  saKne  cathartics,  all  of  which  produce  evacuation 
of  the  bowels  chiefly  by  increasing  the  amount  of  fluid  in  the  intestine. 
They  differ  in  their  action  from  vegetable  cathartics  in  that  they 
stimulate  peristalsis  but  feebly.  They  not  only  hinder  the  absorp- 
tion of  fluid  taken  with  the  food,  but  they  abstract  more  fluid  directly 
from  the  tissues  and  blood.  To  understand  thoroughly  this  so- 
called  salt  action — i.e.,  the  behavior  of  saline  solutions  of  varying 
degrees  of  concentration  in  relation  to  the  saHnity  of  the  blood  serum, 
by  which  a  flow  of  fluid  to  or  from  the  blood  is  determined — it  is 
necessary  that  we  be  familiar  with  certain  physical  processes,  chief 


2l6  CATHARTICS 

among  whicli  is  that  of  osmosis — the  passage  of  salts  through  animal 
membranes,  or  the  force  by  which  fluids  are  impelled  through  organic 
membranes.  If,  for  example,  a  lo  per  cent,  solution  of  common  salt 
is  placed  in  the  bottom  of  a  container  and  water  placed  in  the  top, 
the  two  liquids  being  separated  by  a  more  or  less  permeable  animal 
membrane,  in  a  few  moments  it  will  be  observed  that  the  specific 
gra\'ity  of  the  two  fluids  is  the  same.  By  the  process  of  osmosis, 
then,  the  salt  from  the  solution  in  the  bottom  has  passed  through  the 
membrane,  and  a  5  per  cent,  solution  of  common  salt  on  both  sides 
of  the  separating  medium  is  the  result.  A  semipermeable  membrane 
is  one  which  allows  the  passage  of  one  sort  of  molecules  (usually 
the  solvent),  while  imper\-iou3  to  another  (usually  the  dissolved 
substance).  The  interposition  of  such  a  membrane  between  salt 
solutions  of  varpnCT  degrees  of  concentration  introduces  very  impor- 
tant modincations  in  the  osmotic  process,  and  results  in  the  develop- 
ment of  what  is  termed  osmotic  pressure.  The  walls  of  the  intestines 
are  only  partly  semipermeable;  -i.e.,  they  are  partly  permeable  to 
salts,  though  much  less  readily  than  to  water.  If  two  solutions  hav- 
ing the  same  molecular  concentration  in  dissolved  substance  (i.e., 
equimoleadar)  are  separated  by  a  semipermeable  membrane  imper- 
meable to  the  dissolved  substance,  it  is  e^'ident  that  no  change  of 
Liquid  will  occur.  Such  solutions,  ha\ing  the  same  specific  gra\^ty 
and,  therefore,  the  same  osmotic  tension  or  pressure,  are  called  isotonic 
to  each  other.  In  physiologic  hterature  "isotonic"  usually  means 
solutions  ha\'ing  the  same  concentration  (specific  gra\ity)  as  blood- 
serum,  and  it  is  in  this  sense  that  the  term  is  used  in  these  pages. 
If  one  solution  has  a  greater  concentration  than  the  other  and  the 
separating  medium  be  a  partly  semipermeable  membrane,  like  the 
waUs  of  the  intestines,  water  principally  -^-ill  pass  from  the  weaker 
into  the  stronger  solution  until  both  are  of  the  same  concentra- 
tion. The  stronger  solution  is  then  called  hyperisotonic;  the  weaker, 
hypoisotonic.     Neither  being  isotonic,  they  are  called  anisotonic. 

With  this  knowledge  of  salt  action  we  can  readily  understand  how 
saline  cathartics,  in  normal  subjects,  act  as  hydragogues,  i.e.,  pro- 
duce a  watery  evacuation  of  the  bowels,  and  why  they  are  absorbed 
from  the  intestine  very  slowly  and  in  but  small  quantities,  the 
greater  portion  escaping  from  the  body  in  the  stools.  The  action 
of  sahne  cathartics,  therefore,  is  purely  local,  which  fact  is  sustained 
by  the  further  fact  that  they  do  not  produce  catharsis  when  intra- 
venously injected.  Wlien  saline  cathartics  are  administered  to  an 
anhydremic  patient  (having  a  deficient  amount  of  water  in  the  blood) 
the  process  of  their  action  is  reversed;  instead  of  the  blood  in  the 


SODII   SULPHAS  217 

adjacent  tissues  yielding  its  water  to  the  intestine,  the  blood  ab- 
stracts water  from  the  bowel,  the  greater  portion  of  the  salt  is  ab- 
sorbed, and  purgation  does  not  ensue.  This  means  that  a  hypoiso- 
tonic  solution  of  the  salt  must  necessarily  be  administered,  otherwise 
this  result  would  not  follow.  An  isotonic  or  perhaps  a  hyperiso- 
tonic  solution  with  a  normal  subject  might  be  hypoisotonic  in  cases 
of  anhydremia. 

Magnesium  sulphate  in  concentrated  solution  (hyperisotonic) ,  is 
an  active  hydragogue  cathartic,  producing  in  a  few  hours  a  copious 
watery  evacuation  of  the  bowel  without  much  pain  or  systemic  dis- 
turbance. Dilute  solutions  (hypoisotonic)  do  not  produce  purga- 
tion, but,  the  salt  being  absorbed  in  greater  quantity,  they  act  as 
diuretics,  increasing  the  flow  of  urine. 

Therapeutics. — Magnesium  sulphate,  being  practically  free  from 
irritant  properties,  is  an  excellent  cathartic  for  removing  undigested 
material  from  the  bowel  in  acute  enteritis  and  colitis  (colic).  Stevens 
speaks  favorably  of  saline  cathartics  in  chronic  constipation,  giving 
a  small  dose  before  breakfast,  claiming  that  they  are  sometimes  more 
efficacious  than  vegetable  cathartics.  While  vegetable  cathartics 
are  usually  given  at  night  on  account  of  their  rather  slow  action, 
generally  causing  no  inconvenience  until  morning,  saline  cathartics 
act  more  promptly  and  powerfully  when  given  before  breakfast. 

Saline  cathartics  are  especially  indicated  in  acute  alveolar  abscess 
as  they  deplete  the  engorged  tissues,  preventing  stagnation  of  the 
blood  in  the  affected  part,  thus  aiding  nature  materially  in  prevent- 
ing the  infected  tissues  from  being  broken  down  into  pus.  A  heap- 
ing teaspoonful  of  Epsom  salt  may  be  dissolved  in  a  wineglass  half 
full  of  warm  water,  having  at  hand,  in  another  glass,  some  fr^sh 
water.  By  drinking  the  fresh  water  as  soon  as  the  concentrated 
solution  is  taken,  the  bitter  taste  of  the  drug  will  scarcely  be  noticed. 

Epsom  salt  is  also  used  in  phenol  poisoning,  and  in  acute  lead 
poisoning.  With  phenol,  the  innocuous  phenol  sulphonate  is  formed, 
and  with  the  soluble  salts  of  lead  (acetate)  an  insoluble  sulphate. 

Incompatibles. — Magnesium  sulphate  is  incompatible  with  lead 
acetate  (sugar  of  lead),  silver  nitrate,  alkaline  carbonates,  and 
lime-water. 

SODII  SULPHAS— U.S.P. 

(Sodium  Sulphate;  Glauber's  Salt;  Na2S04.ioH20.) 

Sodimn  sulphate  occurs  in  large,  colorless,  transparent  prisms 
or  granular  crystals,  odorless,  and  having  a  bitter,  saline  taste.     It 


2l8  CATHARTICS 

is  soluble  in   1.2  parts  of  water,  and .  insoluble  in  alcohol.     The 
average  dose  is  4  dr.  (16.0  Gm.). 

Physiologic  Action  and  Therapeutics. — Sodium  sulphate  acts 
as  a  powerful  hydragogue  cathartic,  producing  large  watery  stools. 
Its  action  is  accompanied,  by  considerable  griping,  because  of  which 
Epsom  salt  has  largely  superseded  the  drug.  Sodium  sulphate 
enters  into  the  mixture  known  as  artificial  Carlsbad  salt,  which, 
given  in  doses  of  a  teaspoonful  in  a  glassful  of  hot  water  half  an 
hour  before  breakfast,  makes  an  efi&cient  mild  aperient.  The  formula 
follows:  sodium  sulphate,  5  oz.  (160.0  Gm.);  sodium  bicarbonate, 
2  oz.  (64.0  Gm.);  sodium  chlorid,  i  oz.  (32.0  Gm.).  Both  sodium 
and  magnesium  sulphates  are  active  ingredients  in  certain  natural 
mineral  waters,  like  Hunyadi  Janos,  Carlsbad,  etc.  These  waters 
may  be  given  in  cases  of  pyorrhea  alveolaris  associated  with  rheu- 
matism or  gout. 

SODII  PHOSPHAS— U.S.P. 

(Sodium  Phosphate;  Na2HP04.i2H20.) 

Sodium  phosphate  occurs  in  large,  colorless,  prismatic  crystals, 
without  odor,  but  having  a  cooHng,  saUne  taste.  It  is  soluble  in 
2.7  parts  of  water,  and  insoluble  in  alcohol.  The  dose  is  from  i  gr.- 
4  dr.  (0.06-16.0  Gm.),  depending  on  the  age  of  the  patient.  For  a 
young  child  a  small  amount  only  is  necessary.  The  following 
preparations  are  ofiicial: 

Sodii  Phosphas   Effervescens,   U.S.P.     Dose,    1-8  dr.    (4.0- 

32.0  Gm.). 

Sodii  Phosphas  Exsiccatus,   U.S.P.     Dose,   10-60  gr.   (0.6- 

4.0  Gm.). 

Liquor  Sodii  Phosphatis  Compositus,   U.S.P.,  VIII  (each  fl. 

dr.  (4.0  mils)  contains  i  dr.  (4.0  Gm.)  of  Sodium  Phosphate, 

with  Sodium  Nitrate  and  Citric  Acid).     Dose,  1-3  fl.  dr.  (4.0- 

12.0  mils.). 

Physiologic  Action  and  Therapeutics. — The  manner  of  action 
of  sodium  phosphate  depends  upon  the  quantity  administered.  In 
small  doses  it  acts  as  a  laxative;  in  large  doses,  as  a  purgative.  Its 
mild  action  and  agreeable  taste  especially  commend  it  for  children, 
to  whom  the  proper  doses  may  be  given  in  milk  or  other  Hquid  food. 
Stevens  speaks  favorably  of  the  drug,  given  in  small  doses  in  hot 
water  before  breakfast,  in  chronic  gastric  catarrh  with  constipation, 
also  in  simple  catarrhal  jaundice. 


MAGNESII    CITRAS POTASSII    ET    SODII    TARTRAS  219 

MAGNESII  CITRAS  (Nonofficial) 
(Magnesium  Citrate;  Mg3(C6H507)2.i4H20.) 

Magnesium  citrate  is  obtained  by  dissolving  magnesium  car- 
bonate in  citric  acid.  It  is  a  colorless  substance,  easily  soluble  in 
water.  It  is  only  ofi&cial  in  the  form  of  solution  of  magnesium 
citrate,  which  is  compounded  in  a  specially  prepared  12  fl.  oz. 
(^360.0  mils)  bottle. 

Liquor  Magnesii  Citratis,  U.S. P.  Dose,  6-12  fl.  oz. 
(180.0-360.0  mils). 

In  cases  of  acute  alveolar  abscess  where  it  is  desired  to  administer 
a  saKne  cathartic,  this  solution  is  highly  efi&cacious.  It  is  well 
tolerated  by  the  stomach,  and  its  action  is  effective.  It  is  somewhat 
irritating,  and  should  not  be  administered  when  there  is  any  inflam- 
mation of  the  gastrointestinal  tract.  An  effervescent  salt  of  mag- 
nesium citrate  may  be  obtained  from  the  pharmacies. 

POTASSn  ET  SODn  TARTRA.S— U.S.P. 

(Potassium  and  Sodium  Tartrate;  Rochelle  Salt;  KNaC4H406.4H20.) 

Rochelle  salt  occurs  in  colorless,  transparent,  prismatic  crystals 
or  as  a  white  powder,  without  odor,  but  having  a  cooHng,  saHne 
taste;  soluble  in  about  i  part  of  water.     The  average  dose  is  2}-^ 
dr.  (lo.o  gm.).     It  is  an  essential  constituent  of  the  official  compound 
effervescent  powder. 

Pxilvis  Effervescens  Compositus,  U.S. P.  (Seidlitz  Powder). 
Dose,  I  powder. 

A  dose  of  Seidlitz  powder  is  contained  in  two  different  colored 
papers — one  blue,  the  other  white.  The  blue  paper  contains 
Potassium  and  Sodium  Tartrate,  120  gr.  (8.0  gm.);  and 
Sodium  Bicarbonate,  40  gr.  (2.6  gm.).  The  white  paper 
contains  Tartaric  Acid,  35  gr.  (2.3  gm.).  The  contents  of 
each  paper  should  be  dissolved  separately,  the  two  solutions 
mixed,  and  the  whole  taken  while  effervescence  is  taking 
place. 

Physiologic  Action  and  Therapeutics. — Rochelle  salt  may  be 
given  as  a  hydragogue  cathartic  in  the  same  conditions  for  which 
magnesium  sulphate  was  recommended.  Its  administration  is  more 
agreeable  than  the  latter,  but  its  action  is  less  active.  The  carbonic 
acid  evolved  during  the  effervescence  of  a  Seidlitz  powder  exerts  a 
more  or  less  sedative  influence  on  the  stomach,  as  well  as  making  the 
solution  more  palatable.  As  a  mild  saHne  cathartic,  especially  dur- 
ing the  summer  season,  a  dose  of  Seidlitz  powder  is  highly  efl5.cacious. 


2  20  CATHARTICS 

OLEUM  TIGLU— U.S.P. 

(Croton  Oil.) 

Croton  oil  is  a  fixed  oil  expressed  from  the  seeds  of  Croton  Tiglium, 
a  small  native  tree  of  China,  but  extensively  cultivated  in  India  and 
the  Philippine  Islands.  It  occurs  as  a  yellowish,  viscid  oil,  having  a 
faint  odor  and  an  acrid,  burning  taste.  It  contains  croton-oleic  acid, 
both  free  and  as  a  glycerid,  together  with  several  other  inactive 
fatty  acids.     The  average  dose  of  croton  oil  is  i  min.  (0.05  mil). 

Physiologic  Action  and  Therapeutics. — Croton  oil  is  a  violent 
irritant.  When  appHed,  undiluted,  to  the  skin  it  causes  redness  and 
burning,  followed  by  a  copious  eruption  of  pustules.  When  inter- 
nally administered  it  acts  as  a  powerful  drastic  cathartic,  causing  in 
one  or  two  hours  several  copious  movements  of  the  bowels,  attended 
with  considerable  pain,  and  sometimes  with  nausea.  Large  doses 
produce  all  the  symptoms  of  a  severe  gastroenteritis — burning  sensa- 
tion in  the  stomach,  pain,  etc.  On  account  of  the  ease  with  which  it 
may  be  administered  (small  quantities  being  so  effectual)  the  drug  is 
a  convenient  cathartic  to  give  in  cases  where  the  patient  can  swallow 
only  with  difficulty.  It  may  be  taken  in  a  small  amount  of  oHve  oil 
or  in  a  pill  with  bread-crumbs  as  an  excipient.  The  prompt  irritant 
action  of  croton  oil  on  the  bowel  makes  it  a  useful  revulsant  in  cases 
of  cerebral  congestion;  therefore,  its  effect  is  advantageous  in  uremia, 
apoplexy,  and  acute  mania.  In  cases  like  lead  poisoning,  where  olsti- 
nate  constipation  is  a  concomitant,  the  drug  is  especially  useful. 

Croton  oil  may  be  mixed  with  some  indifferent  oil  (croton  oil, 
I  part;  oHve  oil,  7  parts)  and  used  as  a  dental  counterirritant.  It 
has  no  advantage  here,  however,  over  the  more  generally  used  coun- 
terirritants  (iodin,  mustard,  capsicum,  etc.).  Stevens  speaks  favor- 
ably of  a  mixture  of  croton  oil  (i  part)  and  tincture  of  iodin  (2  parts) 
to  be  used  as  a  pigment  in  neuritis. 

COLYCYNTHIS— U.S.P. 

(Colycynth.) 

Colyc3mth  is  the  fruit  of  Citrullus  Colocynthis  deprived  of  its  rind . 
The  plant  grows  in  arid  places  in  Asia,  Africa,  and  Southern  Europe. 
It  contains  colocynthin,  a  bitter  glucosid,  to  which  its  cathartic  prop-  ^ 
erty  is  largely  due.     The  average  dose  of  colocynth  is  i   gr.   (0.06 
Gm.).     The  following  preparations  are  official: 

Extractum  Colocynthidis,   U.S. P.     Dose,   2-5  gr.   (0.13-0.3 

Gm.). 

Extractum  Colocynthidis  Compositum,  U.S. P.     Dose,  5-20 

gr.  (0.3-1.3  Gm.). 


GAMBOGIA JALAPA  221 

Pilulse  Catharticae  Compositae,  U.S. P.     Dose,  1-3  pills. 
Pilulae  Catharticae  Vegetabiles,  U.S. P.,  VIII.     Dose,  1-3  pills. 

Physiologic  Action  and  Therapeutics. — Coloc}Tith  is  an  ener- 
getic drastic  cathartic,  producing  in  full  doses  copious,  watery  stools, 
accompanied  frequently  by  griping.  In  large  doses  the  irritation 
excites  inflammation  of  the  whole  ahmentary  tract,  which  may  prove 
fatal.  The  drug  is  too  irritant  to  be  used  alone,  and  is  only  given  in 
combination  mth  other  drugs  in  cases  of  obstinate  chronic  constipation, 
which  frequently  accompanies  old  age. 

CAMBOGIA— U.S.P. 

(Gamboge.) 

Gamboge  is  a  gtim-resin  obtained  from  Garcinia  Hanburii,  a 
laurel-like  tree  growing  in  the  East  Indies.  Its  active  principle  is 
cambogic  acid.  The  average  dose  of  the  drug  is  from  2  gr.  (0.13 
Gm.).     It  enters  into  the  following  official  preparation: 

Pilulae  Catharticae  Compositae,  U.S. P.     Dose,  1-3  pills. 

Physiologic  Action  and  Therapeutics. — Gamboge  is  an  active 
drastic  cathartic.  In  large  doses  its  irritant  effect  is  capable  of  caus- 
ing fatal  gastroenteritis.  It  is  never  used  alone,  but  may  be  com- 
bined with  less  powerful  cathartics  and  used  in  obstinate  chronic 
constipation. 

JALAPA— U.S.P. 

(Jalap.) 

Jalap  is  the  tuberous  root  of  Exogonium  Purga,  a  perennial  herb 
growing  in  jMexico.  It  contains  two  resins,  jalapin  and  convol- 
vulin,  both  of  which  are  active.  The  average  dose  of  jalap  is  15  gr. 
(i.o  Gm.). 

Its  official  preparations  follow: 

Resina  Jalapae,  U.S. P.     Dose,  1-5  gr.  (0.06-0.3  Gm.). 
Pulvis  Jalapae  Compositus,   U.S. P.   (contains  Jalap,  35; 
Potassium  Bitartrate,  65).     Dose,  15-60  gr.  (1.0-4.0  Gm.). 
Pilulae  Cathartae  Compositae,  U.S. P.     Dose,  1-3  pills. 
Pilulae  Catharticae  Vegetabiles,  U.S. P.  \T;II  (each  pill  con- 
tains extract  of  Jalap,  }i  gr.-0.03  Gm.;  compound  extract  of 
Colocynth,  about  i  gr.-o.o6  Gm.;  extract  of  Hyoscyamus,  H 
gr.-0.03  Gm.;  extract  of  Leptandra,  3^gr.-o.oi5  Gm.;  extract 
of  Podophyllum,  J^  gr.-0.015  Gm.;  and  Oil  of  Peppermint). 
Dose,  1-3  pills. 

Physiologic  Action  and  Therapeutics. — The  action  of  jalap  is 
more  like  that  of  the  hydragogue  cathartics  than  it  is  of  the  drastic. 


222  DIURETICS 

It  acts  gently,  producing,  within  three  or  four  hours,  copious,  watery 
stools.  Pharmacologists  (Stadelmann,  and  others)  claim  that  the 
drug  has  no  action  in  the  absence  of  bile,  the  latter  serving  in  all 
probability  as  a  solvent.  For  removing  the  water  from  the  tissues  in 
dropsy  the  drug  is  frequently  combined  with  a  sahne,  as  in  the  official 
compound  powder  of  jalap.  It  is  not  employed  alone  as  a  carhartic, 
but  it  is  an  ingredient  of  both  the  official  compound  cathartic  pills 
and  formerly  official  compound  vegetable  pills,  which  preparations 
are  frequently  given  in  habitual  constipation. 

PODOPHYLLUM— U.S.P. 

(May  Apple;  Mandrake.) 

Podophylluin  is  the  rhizome  and  rootlets  of  Podophyllum  peltatum, 
a  perennial  herb,  growing  in  the  moist  woods  of  Canada  and  northern 
United  States.  It  contains  two  isomeric  glucosids,  podophyllotoxin 
and  picropodophyllin,  and  also  a  resin,  podophyllin,  which  is  official. 
The  average  dose  of  podophyllum  is  5  gr.  (0.3  Gm.).  The  official 
preparations  are: 

Resina  PodophyEi,  U.S. P.  Dose,y  i-y^gr.  (0.008-0.03  Gm.). 
Fluidextractum  Podophylli,  U.S. P.  Dose,  5-20  min.  (0.3- 
1.3  mils). 

Pilulae  Podophylli,  Belladonnae  et  Capsici,  U.S. P.  VIII 
(each  pill  contains  Podophyllin,  J^  gr.-o.oi6  Gm. ;  extract  of 
Belladonna,  J^  gr.-o.oo8  Gm.;  pulv.  Capsicum,  3^^  gr.-0.03 
Gm. ;  with  Acacia  and  Sugar  of  Milk).     Dose,  1-2  pills. 

The  resin  is  also  a  constituent  of  compound  cathartic  pills. 

Physiologic  Action  and  Therapeutics. — Podophyllum  is  an 
active  drastic  cathartic.  Its  action  is  rather  slow,  however,  com- 
pared with  most  other  drastics;  it  generally  requires  from  ten  to 
twelve  hours  to  produce  an  evacuation  of  the  bowel.  The  stools 
are  copious  and  watery,  and  usually  attended  with  more  or  less 
griping  pain.  The  drug  is  used  in  habitual  constipation,  associated 
with  so-called  biliousness.  When  combined  with  other  cathartic 
drugs,  those  should  be  selected  which  are  also  slow  in  action,  Uke 
aloes,  calomel,  etc.  The  resin  is  the  most  reliable  preparation  and 
is  generally  given  in  the  form  of  pills. 

DIURETICS 

Diuretics  are  agents  that  increase  the  flow  of  urine.  They  may 
act  indirectly  by  forcing  a  greater  volume  of  blood  through  the 
kidneys,  or  directly  by  stimulating  the  renal  epithelium.     A  number 


POTASSII   BICARBONAS POTASSII    CARBONAS  223 

of  them  act  in  both  ways.  Certain  circulatory  stimulants  also  act 
as  diuretics,  among  which  may  be  mentioned  digitalis  and  caffein; 
digitalis  appears  to  have  no  special  action  on  the  secreting  cells  of 
the  kidneys ;  its  effect  as  a  diuretic  is  almost  entirely  dependent  upon 
the  influence  the  drug  has  over  the  cardiovascular  system.  Caffein, 
on  the  other  hand,  is  a  powerful  diuretic,  acting  directly  on  the  renal 
epithelium,  and,  in  a  lesser  degree,  on  the  circulation. 

The  inorganic  salts,  urea,  and  other  soluble  proteids,  normally 
present  in  the  blood,  may  be  regarded  as  the  physiologic  stimuli  of 
the  secreting  cells  of  the  kidneys.  Many  other  substances,  not 
natural  components  of  the  blood,  increase  the  secretion  of  urine  by 
exerting  a  direct  and  specific  influence  on  the  cells  of  the  glomeruli 
and  convoluted  tubes  (Stevens). 

Diuretics  are  employed  in  dental  practice  principally  for  the 
purpose  of  removing  from  the  blood  certain  excrementitious  matters, 
which  are  supposed  to  be  forerunners  of  pyorrhea  alveolaris.  The 
agents  used  are  chiefly  the  vegetable  salts  of  potassium  and  lithium, 
which  not  only  increase  the  amount  of  urine  excreted,  but,  being 
eliminated  through  the  kidney  in  large  part  as  carbonates,  they 
tend  to  make  the  urine  alkaline  in  reaction.     Examples  follow: 

Potassium  Bicarbonate.  Potassium  Chlorate. 

Potassium  Carbonate.  Potassium  Nitrate. 

Potassium  Citrate.  Lithium  Carbonate. 

Potassium  Acetate.  Lithium  Citrate. 

Potassium  Bitartrate.  Lithium  Benzoate. 

POTASSn  BICARBONAS— U.S.P. 

(Potassium  Bicarbonate;  KHCO3.) 

Potassium  bicarbonate  occurs  in  colorless  prismatic  crystals, 
without  odor,  but  having  an  unpleasant,  saline,  alkaline  taste; 
soluble  in  3  parts  of  water,  and  practically  insoluble  in  alcohol. 
The  average  dose  is  15  gr.  (i.o  gm.).  Potassium  bicarbonate,  though 
not  contained  therein  as  such,  is  used  in  making  the  following  official 
solutions: 

Liquor  Potassii  Arsenitis,  U.S. P.  (Fowler's  Solution). 
Liquor  Potassii  Citratis,  U.S.P. 
Liquor  Magnesii  Citratis,  U.S.P. 

POTASSII  CARBONAS— U.S.P. 

(Potassium  Carbonate;  K2CO3.) 

Potassiiim  carbonate  occurs  in  a  white,  granular,  deliquescent 
powder;   freely  soluble  in  water,   but  insoluble  in   alcohol.     The 


2  24  DIURETICS 

average  dose  is  15  gr.  (i.o  Gm.).  The  drug  is  very  irritant  and 
rarely  used  as  such  internally;  from  potassium  carbonate,  however, 
the  following  official  preparations  are  made : 

Mistura  Ferri  Composita,  U.S.P.  VIII. 
PUulae  Ferri  Carbonatis,  U.S.P.  (Blaud's  Pills). 

POTASSII  CITRAS— U.S.P. 

(Potassium  Citrate;  K3C6H5O7.H2O.) 

Potassium  citrate  occurs  in  transparent,  prismatic  crystals  or 
white,  granular,  deliquescent  powder,  without  odor,  but  having  a 
pleasant  saline  taste;  soluble  in  0.5  part  of  water,  but  sparingly 
soluble  in  alcohol.  The  average  dose  is  i  dr.  (4.0  Gm.).  There  are 
two  official  preparations.     They  are: 

Liquor  Potassii  Citratis,  U.S.P.     Dose,   J^-i   fl.  oz.   (15.0- 
30.0  mils). 

Potassii  Citras  Effervescens,  U.S.P.     Dose,  30-90  gr,  (2.0- 
6.0  Gm). 

POTASSn  BITARTRAS— U.S.P. 

(Potassium  Bitartrate;  Cream  of  Tartar;  KHC4H4O6.) 

Cream  of  tartar  occurs  in  colorless,  or  slightly  opaque,  rhombic 
crystals,  or  as  a  white  powder,  without  odor,  but  having  an  acidulous 
taste;  soluble  in  about  155  parts  of  water,  and  very  sparingly 
soluble  in  alcohol.  The  average  dose  is  15  gr,  (1,0  Gm,).  It  is  a 
component  of  the  following  official  preparation: 

Pulvis  Jalapae  Compositus,  U.S.P.     Dose,  15-60  gr.  (1.0-4.0 
Gm.). 

POTASSII  ACETAS— U.S.P. 

(Potassium  Acetate;  KC2H3O2.) 

Potassium  acetate  occurs  in  the  form  of  a  white  powder  or 
crystalline  masses,  very  deliquescent,  odorless,  and  having  a  pleasant, 
saline  taste;  soluble  in  0.4  part  of  water  and  in  2  parts  of  alcohol. 
The  average  dose  is  15  gr.  (i.o  Gm.). 

Physiologic  Action. — The  vegetable  salts  of  potassium  act 
similarly  and  will,  therefore,  be  discussed  here  conjointly.  The 
potassium  ion  is  much  more  physiologically  active  than  is  the  sodium 
ion,  and  as  a  result  the  potassium  salts,  as  a  rule,  are  more  irritant 
and  depressant  than  are  the  corresponding  sodium  salts.  With  the 
vegetable  salts  of  potassium,  however,  the  action  of  the  base  is 


POTASSII    CHLORAS  225 

entirely  subordinate  to  that  of  the  acid  radical,  and  a  depressant 
effect  is  never  observed  except  when  administered  continuously  or 
in  enormous  doses.  The  dominant  action  of  any  one  of  the  vegetable 
salts  of  potassium  is  upon  the  secreting  cells  of  the  kidneys,  increas- 
ing the  amount  of  urine.  The  mineral  salts  of  the  urine,  both  of 
potassium  and  sodium,  are  increased,  but  the  evidence  is  not  con- 
vincing that  the  vegetable  salts  of  potassium  materially  assist 
oxidation  in  the  tissues,  and  in  consequence  augment  nitrogenous 
elimination.  In  large  doses  they  do,  however,  impart  an  alkaline 
reaction  to  the  urine,  and  in  h}7)erisotonic  solution  they  act  as  saline 
cathartics,  producing  free  watery  discharges.  Potassium  bitartrate 
differs  somewhat  from  the  other  vegetable  salts  of  this  metal  in 
that  it  resists  oxidation  in  the  body,  and,  therefore,  much  of  it  is 
eliminated  unchanged.     It  is  also  a  more  active  cathartic. 

Therapeutics. — Clinical  experience  has  fuUy  demonstrated  that 
acute  rheumatism  is  influenced  favorably  by  the  administration  of 
the  vegetable  salts  of  potassium;  and  it  is  also  true  that  pyorrhea 
alveolaris  in  rheumatic  or  gouty  subjects  is  favorably  influenced  by 
these  salts,  but  until  we  have  a  clearer  understanding  of  the  nature 
of  these  diseases,  it  is  useless  to  speculate  upon  the  mode  of  action 
of  the  remedies  employed  in  their  treatment.  In  these  cases  10-30 
gr.  (0.6-2.0  Gm.)  of  the  salt  maybe  dissolved  in  water  and  admin- 
istered. The  dose  should  be  repeated  every  three  or  four  hours 
until  the  urine  becomes  neutral  or  sHghtly  alkaline.  Both  the  official 
solution  of  potassium  citrate  and  the  effervescent  salt  are  agreeable 
preparations  to  take.  Stevens^  speaks  favorably  of  combining  an 
alkaline  salt  with  a  saHcyHc  compound.  Salophen  may  be  selected 
for  this  purpose,  for  while  it  is  practically  insoluble  in  water,  it  is 
freely  soluble  in  watery  solutions  of  the  alkaline  salts. 

The  vegetable  salts  of  potassium  are  efficient  sedative  expecto- 
rants in  the  beginning  of  acute  bronchitis,  especially  when  the  secre- 
tion is  viscid  and  scanty. 

Incompatibles. — The  vegetable  salts  of  potassium  are  incom- 
patible with  acids,  mineral  salts,  and  alkaloidal  salts. 

POTASSn  CHLORAS— TJ.S.P. 

(Potassium   Chlorate;   KCIO3.) 

Potassium  chlorate  occurs  in  colorless,  crystalline  plates,  with- 
out odor,  but  having  a  cooling  saHne  taste;  soluble  in  11.5  parts  of 

^  Modern  Materia  Medica  and  Therapeutics. 
15 


2  26  DIURETICS 

water,  sparingly  soluble  in  alcohol.     The  average  dose  is  4  gr.  (0.25 
Gm.)-     There  is  one  official  preparation: 

Trochisci  Potassii  Chloratis,  U.S. P.  (each  contains  about  2^-^ 
gr.-0.15  Gm.).     Dose,  1-5  troches. 

Physiologic  Action. — Potassium  chlorate,  when  applied  in  dilute 
form  to  the  mucous  membrane,  acts  as  a  stimulating  alterative;  in 
concentrated  form  it  is  a  decided  irritant.  The  exact  manner  of  its 
action  is  not  fully  understood.  It  was  supposed  formerly  that  the 
drug,  when  internally  administered,  yielded  its  oxygen  to  the  blood, 
but  recent  investigation  tends  to  prove  that  this  theory  is  erroneous 
and  that  fully  90  per  cent,  passes  out  of  the  body  unchanged  in  the 
urine,  though  small  quantities  have  been  detected  in  the  saliva,  tears, 
and  milk  of  nursing  women.  In  moderate  doses,  well  diluted,  its 
only  noticeable  effect  is  to  increase  the  flow  of  urine. 

Poisoning  and  Treatment. — In  excessively  large  doses  potassium 
chlorate  produces  toxic  symptoms.  Its  basic  radical  or  potassium 
ion  depresses  the  circulation  and  nervous  system,  while  its  acid  radi- 
cal or  chlorate  ion  irritates  the  stomach,  intestines,  and  kidneys. 
In  the  treatment  of  poisoning  the  stomach  should  be  evacuated  by 
emetics  or  the  stomach-pump,  followed,  as  usual,  with  demulcents. 
In  case  of  exhaustion,  physiologic  salt  solution  may  be  subcutane- 
ously  injected. 

Therapeutics. — In  all  inflammatory  conditions  of  the  mouth  and 
throat,  potassium  chlorate  makes  an  excellent  local  application. 
Ten  grains  (0.6  Gm.)  to  the  ounce  (30.0  mils)  may  be  used  as  a  wash, 
gargle,  or  spray.  In  mercurial  stomatitis,  the  salt  is  almost  a  specific, 
and  may  be  employed  internally  as  well  as  locally.  It  is  quite  gen- 
erally believed  by  medical  men  that  salivation  is  less  likely  to  follow 
the  continuous  use  of  mercury  in  secondary  syphilis  when  a  solution 
of  potassium  chlorate  is  simultaneously  used  as  a  mouth- wash. 
Cushney^  states  that  the  drug  may  be  given  internally  as  a  prophy- 
lactic to  prevent  stomatitis  when  mercury  is  being  prescribed,  but 
that  it  does  not  prevent  the  saHvation.  Oral  prophylaxis  and  mouth 
hygiene  are  considered  important  factors  in  the  treatment  of  syphilis 
to-day. 

The  drug  is  used  as  a  constituent  of  dental  pastes  which  have 
gained  some  prominence  as  a  cure  for  many  mouth  diseases.  The 
amount  of  potassium  chlorate  in  these  pastes  ranges  from  10  to  50 
per  cent.,  and  in  this  strength  they  should  not  be  appHed  to  the 
mucous  membrane  of  the  mouth,  as  harm  is  Hkely  to  follow.     Where 

^  Pharmacology  and  Therapeutics,  or  the  Action  of  Drugs. 


POTASSII   NITEAS LITHII    CARBONAS  227 

the  drug  is  indicated,  it   is  far  better  to  confine  its  use   to  weak 
solutions. 

Incompatibles. — Potassium  chlorate,  being  rich  in  oxygen  which 
it  readily  gives  up,  makes  the  drug  incompatible  with  many  easily 
oxidizable  substances,  Hke  sulphur,  phosphorus,  pulverized  charcoal, 
tannic  acid,  sugar,  sulphids,  hyposulphites,  hj-pophosphites,  and 
ammonium  chlorid. 

POTASSn  NITRAS— U.S.P. 

(Potassium  Nitrate;  Saltpeter;  KXO3.) 

Potassium  nitrate  occurs  in  colorless,  transparent,  rhombic 
prisms  or  as  a  crystalline  powder,  odorless,  and  having  a  cooling 
saline  taste;  soluble  in  3.6  parts  of  water,  sparingly  soluble  in  alcohol. 
The  average  dose  is  8  gr.  (0.5  Gm.)  in  solution,  well  diluted. 

Physiologic  Action  and  Therapeutics, — Except  that  it  is  more 
irritating  to  the  stomach,  the  action  of  potassium  nitrate  in  moderate 
doses  does  not  differ  materially  from  the  vegetable  salts  of  potas- 
sium ;  it  increases  the  secretion  of  urine  through  direct  action  on  the 
renal  epithelium.  In  large  doses  potassium  nitrate  is  not  only  more 
irritating  than  the  vegetable  salts,  but  is  markedly  more  depressant 
to  the  heart  and  nervous  system;  for  here  the  action  of  the  base 
(potassium)  is  not  subordinate  to  that  of  the  acid  radical.  Toxic 
doses  produce  the  symptoms  of  gastroenteritis,  muscular  weakness, 
and  collapse. 

Potassium  nitrate  is  not  used  in  dental  therapeutics.  It  has 
been  employed  in  general  dropsy,  but  it  has  no  greater  efficacy  than 
the  less  irritating  vegetable  salts.  Inhalations  of  the  smoke  of 
burning  niter  paper,  formerly  official,  sometimes  afford  relief  in 
asthma.  Solutions  of  the  drug,  caUed  "brine,"  are  useful  for  pre- 
serving meats.  A  mixture  of  equal  parts  of  potassium  nitrate  and 
borax  makes  a  most  excellent  reducing  agent  for  refining  gold  scrap. 
The  latter  should  be  placed  on  charcoal  and  fused,  when  the  "oxidiz- 
ing mixture"  is  added.  The  potassium  nitrate  will  oxidize  the  base 
metals  which  oxids  are  dissolved  by  the  borax  and  absorbed  by  the 
charcoal,  leaving  the  gold  practically  pure. 

LITHH  CARBONAS— U.S.P. 

(Lithium   Carbonate;  Li2C03.) 

Lithium  carbonate  occurs  as  a  white  powder,  without  odor,  but 
having  an  alkahne  taste;  soluble  in  75  parts  of  water  and  insoluble 
in  alcohol.     The  average  dose  is  8  gr.  (0.5  Gm.).^ 


2  28  DIAPHORETICS 

LITHH  CITRAS— U.S.P. 

(Lithium  Citrate;  Li3C6H507.4H20.) 

Lithiiim  citrate  occurs  as  a  white,  deliquescent  powder,  without 
odor,  but  having  a  cooling  saline  taste;  soluble  in  2  parts  of  water, 
insoluble  in  alcohol.     The  average  dose  is  8  gr.  (0.5  Gm.). 

Physiologic  Action  and  Therapeutics. — The  action  of  the  vege- 
table salts  of  lithium  is  very  similar  to  that  of  the  corresponding  salts 
of  potassium,  because  the  action  of  the  base  in  both  groups  is  en- 
tirely subordinate  to  that  of  the  acid  radical.  They  increase  the 
quantity  of  urine  and  lessen  its  acidity. 

The  salts  of  lithium  have  been  recommended  in  the  treatment  of 
gout  and  the  uric  acid  diathesis  because  it  was  found  that  outside  of 
the  body  lithium  united  with  uric  acid  to  form  a  more  soluble  salt 
than  did  either  potassium  or  sodium,  but  since  it  has  been  clearly 
demonstrated  that  alkaline  medication  is  without  influence  on  the 
uratic  salts  present  in  the  blood  or  tissues,  it  is  doubtful  whether 
the  salts  of  lithium  are  any  more  potent  in  these  diseases  than  are 
the  vegetable  salts  of  potassium  (Stevens).  On  the  hypothesis  that 
the  concretions  in  pyorrhea  alveolaris  were  precipitated  and  deposited 
on  the  roots  of  teeth  as  the  blood,  supercharged  with  suboxidized  or 
excrementitious  material,  slowly  passed  through  the  pericemental 
membrane,  lithium  salts  and  the  natural  mineral  waters  have  been 
extensively  employed  in  the  treatment  of  this  condition.  But,  as 
above  mentioned,  since  it  is  clearly  proven  that  lithium  salts  are 
without  influence  on  the  urates  in  the  blood  or  tissues,  and  since, 
too,  it  has  never  been  clearly  demonstrated  that  the  deposits  are 
formed  from  the  source  mentioned,  it  is  indeed  doubtful  whether 
these  salts  play  any  role  in  the  eradication  of  the  disease,  except  to 
increase  the  amount  of  urine.  In  the  case  of  the  natural  waters, 
the  eflacacy  which  they  may  possess  in  this  disease  is  probably  de- 
pendent upon  the  depurant  (purifying)  action  of  the  water  itself, 
and  not  upon  the  small  amount  of  salt  they  contain.  On  this  basis, 
the  drinking  of  large  quantities  of  pure,  wholesome  water  in  the 
treatment  of  this  disease  is  recommended. 

DIAPHORETICS 

Diaphoretics  are  agents  which  promote  the  secretion  of  perspira- 
tion. When  the  action  of  the  remedy  is  such  that  the  sweat  stands 
in  beads  upon  the  surface,  it  is  called  a  sudorific. 

The  agents  employed  may  act  directly  by  stimulating  the  special 


PILOCARPUS  229 

nerve  fibers  supplying  the  sweat  glands,  indirectly  by  stimulating 
the  sweat  centers  of  the  central  nervous  system  from  which  those 
fibers  originate,  or  reflexly  by  irritating  peripheral  sensory  nerves. 
The  activity  of  the  sweat  glands  is  increased  by  dilatation  of  the 
peripheral  vessels,  external  heat,  muscular  exercise,  dyspnea,  strong 
emotion,  nausea,  and  various  drugs  (Stevens).  Diaphoretics  are 
chiefly  used  for  their  evacuant,  revulsive,  and  alterative  effects,  and 
also  to  promote  absorption.  The  drugs  usually  employed  for 
promoting  perspiration  are : 

Pilocarpus.  Liquor  Ammonium  Acetate. 

Spirit  of  Nitrous  Ether.  Opium.* 

PILOCARPUS— U.S.P. 

(Jaborandi.) 

Pilocarpus  is  the  leaflets  of  Pilocarpus  Jaborandi  and  Pilocarpus 
microphyllus,  shrubs  growing  in  South  America.  It  contains  three 
alkaloids — pilocarpin,  pilocarpidin,  and  isopilocarpin — all  of  which 
are  physiologically  *  active,  but  pilocarpin  is  the  most  active,  is 
present  in  greater  quantity,  and  yields  with  acids  soluble  crystalline 
salts,  of  which  two  are  official:  Pilocarpines  Nitras,  U.S. P.,  and 
Pilocarpines  Hydrochloridum,  U.S.P.  These  salts  are  most  com- 
monly used;  the  average  dose  of  either  is  by  mouth,  3^  gr.  (o.oi 
Gm.);  hypodermic,  3d^2  gr-  (o-oo5  Gm.).  The  average  dose  of  pilo- 
carpus is  30  gr.  (2.0  Gm.).  There  is  one  ofi&cial  preparation  of  the 
drug. 

Fluidextractum  Pilocarpi,  U.S.P.     Dose,  10-60  min.  (0.6- 

4.0  mils). 

Physiologic  Action  and  Therapeutics. — Probably  no  other  single 
drug  exerts  the  same  influence  on  the  secretory  glands  of  the  body 
as  pilocarpin.  When  internally  administered,  even  in  small  doses, 
the  sweat  and  saliva  are  markedly  increased.  It  also  increases, 
but  to  a  lesser  degree,  the  lacrimal,  nasal,  bronchial,  gastric,  intes- 
tinal, and  renal  secretions.  The  fact  that  atropin  completely  sus- 
pends the  efl'ect  of  pilocarpin  on  the  secretions  has  led  pharmacolo- 
gists to  believe  that  the  drug  acts  by  stimulating  the  peripheral 
fibers  of  the  nerves  supplying  the  various  glands. 

Pilocarpin  is  not  much  used  in  dental  therapeutics.  In  acute 
uremia  large  doses  3^-3^  gr.  (0.01-0.02  Gm.)  may  be  used  in  con- 
junction with  external  heat  (hot  air  or  hot  vapor  baths).  The  drug 
is  sometimes  used  for  its  diaphoretic  effect  in  acute  rheumatism  and 
acute  coryza. 


230  EMETICS 

SPIRITUS  ^THERIS  NITROSI— U.S.P. 

(Spirit  of  Nitrous  Ether;  Sweet  Spirit  of  Niter.) 

Spirit  of  nitrous  ether,  commonly  called  sweet  spirit  of  niter, 
is  an  alcoholic  solution  of  ethyl  nitrite,  containing  not  less  than  4 
per  cent,  of  pure  ethyl  nitrite.  It  occurs  as  a  clear,  volatile,  inflam- 
mable liquid,  having  a  yellowish  or  greenish  tint,  a  pleasant  ethereal 
odor,  and  a  sharp,  burning  taste.  It  should  be  kept  in  well-stop- 
pered bottles  away  from  light.  The  dose  is  from  10-120  min.  (0.6- 
8.0  mils),  depending  upon  the  age  of  the  patient. 

Physiologic  Action  and  Therapeutics. — Spirit  of  nitrous  ether 
acts  as  a  mild  diaphoretic,  diuretic,  and  antispasmodic.  Its  diapho- 
retic effect  is  more  pronounced  than  its  diuretic  effect  when  the 
patient  is  kept  well  under  cover  after  its  administration;  the  action 
is  reversed  when  the  patient  is  lightly  covered.  It  appears,  therefore, 
that  external  heat  augments  its  diaphoretic  action. 

Sweet  spirit  of  niter  is  used  extensively  as  an  antispasmodic 
remedy  in  convulsions  which  frequently  occur  in  children  during  the 
eruptive  period  of  the  deciduous  teeth.  It  is  best  given  in  small  doses, 
at  frequent  intervals,  weU  diluted  with  water. 

LIQUOR  AMMONH  ACETATIS— U.S.P. 

(Solution  of  Ammonium  Acetate;  Spirit  of  Mindererus.) 

This  is  a  solution  of  diluted  acetic  acid  nearly  saturated  with 
ammonium  carbonate.  It  should  be  slightly  acid  in  reaction,  con- 
tain about  7  per  cent,  of  ammonium  acetate,  and  prepared  as  wanted. 
Somewhat  like  sweet  spirit  of  niter,  it  acts  as  a  feeble  diaphoretic  or 
diuretic  according  as  the  patient  is  kept  warm  or  cool.  It  is  largely 
used  in  mild  febrile  affections  of  children  as  a  vehicle  for  spirit  of 
nitrous  ether  or  preparations  of  aconite.  The  average  dose  is 
4  fl.  dr.  (15.0  mils). 

EMETICS 

Emetics  are  agents  which  produce  vomiting  (emesis) .  It  is  sup- 
posed that  drugs  act  to  produce  emesis  either  by  directly  affecting 
the  center  in  the  medulla  or  by  indirectly  affecting  it  through  irrita- 
tion of  the  sensory  nerve  endings  in  the  stomach.  There  is  little 
doubt  that  the  action  of  apomorphin  is  a  direct  one;  ipecac  and 
antimony  undoubtedly  act  both  directly  and  indirectly;  and  all 
evidence  goes  to  show  that  zinc  sulphate,  copper  sulphate,  alum, 
mustard,  and  tepid  water  act,  in  the  main  at  least,  indirectly. 


APOMORPHIN^    HYDROCHLORIDUM  23 1 

Emetics  may  be  used  for  one  of  four  purposes : 

1.  To  expel  poisons,  or  undigested  food  which  is  causing  pain, 
headaches,  etc.,  from  the  stomach.  For  this  purpose  the  indirect 
or  local  emetics  are  the  most  reliable,  especially  in  cases  of  poisoning. 

2.  To  expel  foreign  bodies,  false  membranes,  or  excessive  secre- 
tion from  the  respiratory  tract;  the  effort  of  vomiting  often  being 
sufficient  to  dislodge  and  remove  the  membrane  or  foreign  body. 
For  this  purpose  the  direct  or  systemic  emetics  should  be  used. 

3.  To  expel  foreign  bodies  from  the  esophagus.  Diret  ore 
systemic  emetics  are  here  also  indicated. 

4.  To  expel  mucus  and  bile  from  the  gall-ducts  in  catarrhal 
jaundice.  For  this  purpose  the  direct  or  systemic  emetics  are, 
perhaps,  the  most  useful. 

Emetics  are  principally  used  in  dental  therapeutics  for  the  im- 
mediate expulsion  of  poisons  that  may  have  been  swallowed  acci- 
dentally or  otherwise.  It  should  be  remembered  that  for  this 
purpose  the  local  emetics  are  employed. 

The  chief  emetics  are: 

Apomorphin.  Copper  Sulphate.* 

Ipecac  (emetin).  Alum.* 

Tartar  Emetic.  Mustard.* 

Zinc  Sulphate.*  Tepid  Water,  in  quantity. 

APOMORPHINiE  HYDROCHLORIDUM— U.S.P. 

(Apomorphin  Hydrochlorid.) 

Apomorphin  is  an  artificial  alkaloid  obtained  from  morphin  by 
abstracting  a  molecule  of  water.  It  is  official  as  the  hydrochlorid, 
which  occurs  in  minute,  grayish-white,  acicular  crystals,  odorless, 
and  having  a  slightly  bitter  taste;  soluble  in  about  50  parts  of  water 
or  alcohol.  The  average  dose  as  an  emetic  by  mouth  is  3^^  gr.  (o.oi 
Gm.) ;  hypodermic,  ^■{2  gr-  (0-005  Gm.) ;  as  an  expectorant,  ^^0  gr. 
(0.003  Gm.). 

Physiologic  Action  and  Therapeutics. — From  five  to  twenty 
minutes  after  ingestion,  according  to  the  dose  and  method  of  admin- 
istration of  apomorphin,  vomiting  ensues,  being  repeated  three  or 
four  times  at  intervals  of  about  fifteen  minutes.  The  emesis  is 
preceded  and  attended  by  slight  nausea,  but  with  moderate  depres- 
sion. The  entire  action  of  apomorphin  is  upon  the  medulla;  it 
is,  therefore,  a  direct  or  systemic  emetic,  being  the  most  powerful 
and  certain  we  possess;  and  is  used  whenever  such  an  emetic  is 
indicated. 


232  EMETICS 

IPECACUANHA— U.S.P. 

(Ipecac.) 

Ipecac  is  the  root  of  Cephaelis  Ipecacuanha,  or  Cephaelis  acumi- 
nata, a  perennial  shrub  gro'^'ing  in  Brazil  and  other  South  American 
states.  It  contains  two  alkaloids,  emetin  and  cephaelin;  and,  accord- 
ing to  some  authorities,  also  psychrotin.  The  average  dose  of  the 
powdered  drug  as  an  emetic  is  15  gr.  (i.o  Gm.);  as  an  expectorant, 
3^  gr.  (0.03  Gm.). 

The  following  are  its  official  preparations : 

Fluidextractum  Ipecacuanhse,  U.S. P.  Dose,  as  an  emetic, 
15-30  min.  (i.a-2.0  mils);  as  an  expectorant,  2-5  min.  (o.i- 
0.3  nul). 

Syrupus  Ipecacuanhas,  U.S. P.  Dose,  as  an  emetic,  2-4  fl.  dr. 
(8.0-15.0  mils);  as  an  expectorant,  10-60  min.  (0.6-4.0  mils). 
Pulvis  Ipecacuanhse  et  Opii,  U.S. P.  (Dover's  Powder;  Ipecac, 
I  part;  Opium,  i  part;  Sugar  of  Milk,  8  parts).  Dose,  5-10  gr. 
(0.3-0.6  Gm.). 

The  action  of  ipecac  is  dependent  almost  entirely  on  its  emetin 
content.     This  alkaloid  is  now  official  as  the  hydrochlorid. 

EMETINiE  HYDROCHLORIDUM— U.S.P. 

This  product  is  the  hydrochlorid  of  the  alkaloid  emetin,  obtained 
from  ipecac.  It  contains  various  amounts  of  water  of  crystallization, 
and  should  be  preserved  in  dark  amber-colored  vials,  protected  from 
light.  The  average  hypodermic  dose  is  ^^  gr.  (0.02  Gm.).  Most 
pharmaceutical  houses  prepare  the  drug  in  solution  in  ampules,  con- 
taining the  average  dose. 

Alcresta  Ipecac  Tablets. — These  are  tablets  containing  an  ab- 
sorption product  of  ipecac  alkaloids  with  hydrated  aluminum  silicate, 
each  tablet  representing  10  gr.  (0.64  Gm.)  of  ipecac.  The  dose  is 
2  or  3  tablets  three  times  a  day  for  a  period  of  four  to  six  days,  then 
discontinued  for  two  or  three  days  if  the  laxative  effect  is  too 
pronounced.  In  the  stomach  where  the  content  is  acid,  the  tablets 
disintegrate  but  do  not  liberate  the  ipecac  alkaloids.  The  latter 
are  released  in  the  intestines  where  the  secretions  are  alkaline,  and 
thus  enter  the  circulation.  Alcresta  ipecac  tablets  afford  a  means 
of  administering  ipecac  by  way  of  the  mouth  without  the  nausea 
which  is  certain  to  follow  the  mouth  administration  of  the  drug  in 
other  forms. 

Physiologic  Action  and  Therapeutics. — Ipecac  is  a  powerful  irri- 
tant to  the  mucous  membranes  of  the  respiratory  tract  when  the 


ANTIMONII    ET    POTASSII    TARTRAS  233 

powdered  drug  is  inhaled.  Its  prolonged  application  to  the  skin 
produces  much  irritation,  and  even  vesication,  pustulation,  and 
ulceration  often  result.  The  drug  is  claimed  to  possess  some  anti- 
septic properties.  Internally  administered  in  small  doses,  ipecac 
acts  as  a  stimulant  to  the  salivary  and  gastric  glands;  its  action  here 
is  not  unHke  that  of  the  vegetable  bitters.  In  large  doses  the  drug 
is  a  powerful  irritant  and  emetic,  the  emesis  in  all  probability  being 
due  to  both  a  local  irritation  of  the  peripheral  sensory  nerve  endings 
in  the  stomach  and  some  slight  action  on  the  medulla  itself. 

The  drug  also  exerts  a  favorable  influence  on  the  bronchial 
mucous  membrane,  acting  as  a  sedative  expectorant,  and  is  fre- 
quently employed  as  a  component  of  cough  mixtures.  Ipecac, 
though  not  very  prompt  in  its  action,  is  a  safe  and  reliable  emetic. 
It  is  especially  useful  in  children,  with  whom  it  is  extensively  used 
to  expel  irritant  material  from  the  stomach. 

The  drug  has  been  empirically  used  for  a  variety  of  purposes 
other  than  that  of  an  emetic  and  expectorant.  It  is  used  as  an 
antiemetic,  antidysenteric,  diaphoretic,  etc.  Recently  ipecac,  or  its 
alkaloid  emetin,  has  gained  a  wide  reputation  in  amebic  dysentery 
and  all  other  diseases  due  to  pathogenic  amehas.  It  has  been  claimed 
that  pyorrhea  alveolaris  is  caused  by  pathogenic  amebas;  and,  on 
this  basis,  emetin  is  recommended  in  the  treatment  of  this  disease 
(which  see,  p.  436).  The  drug  may  be  administered  in  the  form  of 
alcresta  ipecac  tablets. 

ANTIMOim  ET  POTASSn  TARTRAS— U.S.P. 

(Antimony  and  Potassium  Tartrate;  Tartar  Emetic; 
2K(SbO)C4H406.H20.) 

Tartar  emetic  occurs  in  the  form  of  colorless,  transparent  crystals 
or  as  a  white  granular  powder,  odorless,  and  having  a  sweetish, 
metallic  taste ;  soluble  in  1 2  parts  of  water,  and  practically  insoluble 
in  alcohol.  The  average  dose  as  an  emetic  is  i  gr.  (0.06  Gm.) ;  as 
an  expectorant,  ^2  gr.  (0.005  Gm.).  The  official  preparations 
are: 

Mistura   Glycyrrhizae  Composa,  U.S.P.  (contains  Extract  of 

Glycyrrhiza,  3;  Antimony  and  Potassium  Tartrate,  0.024; 

Syrup,  5;  Acacia,  3;  Camphorated  Tincture  of  Opium,  12; 

Spirit  of  Nitrous  Ether,  3;  Water  to  make  100).     Dose,  2H 

fl.  dr.  (10. o  mils). 

Syrupus  Scillae  Compositus,  U.S.P.  (contains  Tartar  Emetic, 

2;  Squill,  Senega,  Sugar,  and  Water  to  make  1,000).     Dose, 

5-60  min.  (0.3-4.0  mils). 


234  EXPECTORANTS 

Physiologic  Action  and  Therapeutics. — Tartar  emetic  is  an  irri- 
tant and  acts  as  an  emetic  and  expectorant.  The  drug  is  fast  falling 
into  disuse  in  medical  practice,  having  been  displaced  largely  by 
other  drugs  which  are  more  prompt  in  their  action  and  less  de- 
pressing. There  is  Httle  need  of  the  drug  in  dental  therapeutics,  but 
it  has  been  considered  here  because  of  its  past  record  as  an  emetic, 
sedative  expectorant,  diaphoretic,  and  counterirritant. 

Tepid  water  in  large  quantities  generally  acts  as  an  emetic. 

EXPECTORANTS 

Expectorants  are  drugs  which  modify  the  secretion  of  mucus 
from  the  mucous  membrane  of  the  air-passages,  affect  its  quantity, 
and  faciHtate  its  expulsion.  The  exact  mode  of  their  action  is  not 
well  understood.  Those  that  promote  secretion  and  render  it  less  vis- 
cid in  character,  and,  therefore,  more  easily  removed,  are  generally 
called  sedative  expectorants.     Examples  of  this  class  are: 

Ipecac*  Tartar  Emetic* 

Apomorphin.*  Potassium  Citrate.* 

Those  drugs  which  stimulate  the  mucous  membrane  of  the  respira- 
tory tract  and  lessen  the  quantity  of  sputum  are  termed  stimulant 
expectorants.     The  most  important  are : 

Ammonium  Chlorid.  Squill. 

Eucalyptus  (Eucalyptol) . *  Benzoic  Acid.* 

Oil  of  Myrtle. 

AMMONH  CHLORIDUM— U.S.P. 

(Ammonium  Chlorid;  Sal  Ammoniac;  NH4CI.) 

Ammonium  chlorid  occurs  as  a  white  crystalline  powder,  odor- 
less, and  having  a  coohng,  saline  taste;  soluble  in  2.6  parts  of  water 
and  in  100  parts  of  alcohol.  The  drug  has  the  pecuUar  physical 
property  of  passing,  when  heated,  directly  from  the  sohd  to  the 
gaseous  state,  and  on  cooHng,  from  the  gaseous  directly  to  the  soHd 
state.  In  other  words,  it  differs  from  most  salts  in  that  it  cannot 
be  Hquefied  by  heat.  The  average  dose  is  5  gr.  (0.3  Gm.).  The 
following  preparation  is  ofl5.cial: 

Trochisci  Ammonii  Chloridi,  U.S. P.  (each  contains  Ammon- 
ium Chlorid,  i}4  gr.  o.i  Gm.;  Extract  of  Licorice,  3  gr.  0.2 
Gm.;  with  Tragacanth,  Sugar,  and  Syrup  of  Tolu).  Dose,  1-2 
troches. 


SCILLA OLEUM    MYRTI  235 

Physiologic  Action  and  Therapeutics. — Administered  in  moderate 
doses  by  the  mouth,  ammonium  chlorid  acts  chiefly  as  a  stimulant 
to  the  mucous  membrane  of  the  respiratory  tract  and  perhaps,  also, 
of  the  stomach  and  bowel.  It  increases  the  quantity  and  renders 
less  viscid  the  mucous  secretion.  The  drug  for  the  most  part  is 
eliminated  in  the  urine  unchanged. 

Ammonium  chlorid  is  extensively  employed  as  a  stimulant 
expectorant  in  acute  bronchial  catarrh,  subacute  and  chronic  pharyngitis, 
etc. 

Incompatibles. — The  drug  is  incompatible  with  alkalies,  mineral 
acids,  tartaric  acid,  and  the  soluble  salts  of  silver  and  lead. 

SCILLA— U.S.P. 

(Squill.) 

Squill  is  the  bulb  of  Urginea  maritima,  a  perennial  herb,  growing 
on  the  shores  of  the  Mediterranean  Sea.  It  is  supposed  to  contain 
several  active  principles,  no  one  of  which,  when  isolated,  fully  repre- 
sents the  activity  of  the  crude  drug.  The  average  dose  is  i3'^  gr. 
(o.i  Gm.).     The  official  preparations  are: 

Acetum  Scillae,  U.S.P.     Dose,  10-30  min,  (0.6-2.0  mils). 
Tinctura  Scillae,  U.S.P.     Dose,  5-20  min.  (0.3-1.3  mils). 
Fluidextractum    Scillae,    U.S.P.     Dose,    1-3    min.    (0.06-0.2 
mil). 

Syrupus  Scillae,  U.S.P.     Dose,  ^-i  fl.  dr.  (2.0-4.0  mils). 
Syrupus  Scillae  Compositus,  U.S.P.   (contains  fluid  extract 
of  Squill,  8  per  cent.;  fluid  extract  of  Senega,  8  per  cent.; 
Tartar  Emetic,  2  per  cent.).     Dose,  10-60  min.  (0.6-4.0  mils). 

Physiologic  Action  and  Therapeutics. — The  action  of  squill 
somewhat  resembles  that  of  digitalis,  though  it  is  much  less  powerful. 
It  also  acts  as  a  stimulant  expectorant  and  a  diuretic.  The  syrup  of 
squill  is  a  common  component  of  cough  mixtures. 

OLEUM  MYRTI  (Nonofficial) 
(Oil  of  Myrtle;  Myrtol.) 

Oil  of  myrtle  is  a  greenish-yellow,  volatile  oil,  distilled  from  the 
leaves  a,nd  flowers  of  Myrtus  communis,  the  common  European  myrtle. 
Its  properties  are  almost  identical  with  those  of  eucalyptol.  The 
average  dose  is  5  min.  (0.3  mil).  It  may  be  employed  as  a  stimu- 
lant expectorant  in  cases  of  cold  in  the  head.  A  few  minims  may  be 
added  to  a  basin  of  hot  water  and  the  fumes  inhaled.     It  may  also  be 


236  SIALOGOGUES 

taken  internally  by  placing  2-3  min.  (0.13-0.2  mil)  of  the  oil  on  a 
blank  sugar  tablet  or  a  piece  of  loaf-sugar.  Harlan  recommends  the 
drug  for  the  treatment  of  gangrenous  pulps,  but  it  is  of  doubtful 
value,  other  remedies  for  this  purpose  having  completely  displaced 
the  essential  oils. 

SIALOGOGUES 

Sialogogues  are  drugs  or  remedies  which  stimulate  the  salivary 
and  buccal  mucous  glands,  increasing  the  secretion  and  flow  of 
sahva  and  buccal  mucus.  There  are  many  diseases  and  conditions 
which  change  the  character  and  flow  of  the  mouth  secretions. 
Among  the  men  who  have  experimented  with  mouth  secretions  in 
relation  to  health  and  disease  may  be  mentioned  Black,  Miller, 
Williams,  Michaels,  Kirk,  Acre,  Hinkins,  Cook,  Bunting,  and  Howe. 
Michaels  claims  that  the  saliva  is  pathognomonic  of  certain  diseases, 
the  diagnosis  being  made  by  physical  and  chemic  examinations 
of  the  saliva.  Cook  has  shown  that  astringent  mouth-washes  inter- 
fere for  hours  with  the  action  of  ptyalin  upon  starchy  food.  The 
mixed  saliva  is  normally  alkaline  in  reaction.  The  author,  collab- 
orating with  Hinkins  and  Cook,  spent  considerable  time  investigat- 
ing the  cause  of  erosion.  One  point  established  beyond  doubt, 
which  has  also  been  mentioned  by  other  investigators,  was  that  the 
saliva  in  typical  cases  of  erosion  is  always  acid.  Hinkins  has  repeat- 
edly called  attention  to  the  fact  that  simply  holding  the  mouth  open 
for  any  length  of  time,  as  in  dental  operations  where  the  rubber 
dam  is  used,  materially  affects  the  character  and  flow  of  saliva. 
Chewing  a  piece  of  clean  wood,  rubber,  and  even  gum  or  tobacco, 
augments  the  flow  of  sahva,  as  does  also  the  smell  of  victuals.  Many 
drugs  also  produce  a  sialogogue  effect,  the  most  important  of  which 
have  been  discussed  under  other  headings.     They  are: 

Pilocarpus  (Jaborandi).*  Potassium  Chlorate.* 

Mercurials.*  Echafolta.* 

lodin  Compounds.*  Tobacco.* 

Acetic  Acid.* 

To  collect  saliva  for  experimental  purposes  almost  any  clean 
substance  may  be  chewed;  the  mere  movements  of  the  jaws  stimu- 
late the  glands.  Another  means  is  to  place  the  tongue  on  the  roof  of 
the  mouth  and  inhale  dilute  acetic  acid  through  the  mouth.  This 
stimulates  the  secretion  especially  from  the  sublingual  gland. 

The  role  played  by  the  saliva  in  mouth  diseases  is  by  no  means 
settled,  and  this  field  offers  an  excellent  opportunity  for  further  inves- 
tigation to  those  scientifically  incHned. 


C  ARMEST  AT  R'E  S  237 

CARMINATIVES 

Carminatives  are  drugs  that  aid  in  the  expulsion  of  gas  from  the 
stomach  or  intestines.  The  gas  found  in  the  alimentary  canal  comes 
from  various  sources:  it  may  have  been  swallowed  with  the  food, 
formed  by  the  action  of  acid  upon  the  carbonates  contained  in  the 
food  and  saliva,  or  it  may  be  generated  through  fermentation  or 
putrefaction  of  the  stomach  contents;  fermentation  being  the  most 
common  cause  of  abnormal  accumulation  of  gas.  Although  drugs 
of  this  class  are  chiefly  valuable  in  the  expulsion  of  gas  already 
formed,  they  also  prevent,  in  greater  or  less  degree,  the  formation 
of  flatus,  for,  by  quickening  the  gastric  circulation,  they  doubtless 
stimulate  glandular  activity,  thus  acting  as  stomachics  by  aiding 
digestion  and  lessening  fermentation.  Carminatives  are  frequently 
combined  with  purgative  drugs ;  here  they  act  as  correctives  by  modify- 
ing or  correcting  the  griping  pain  which  purgatives  are  hkely  to 
induce  when  given  alone. 

Most  of  the  drugs  belonging  to  this  class  are  aromatics  containing 
essential  oils  as  their  chief  active  constituent.  Alcohol,  ether,  and 
chloroform  are  the  exceptions.     The  principal  carminatives  are: 


Capsicum.* 

Cardamom. 

Caraway. 

Pepper. 

Cloves.* 

Fennel. 

Nutmeg. 

Cinnamon.* 

Coriander. 

Ginger, 

Anise. 

Mustard.  * 

Peppermint.* 

Allspice. 

Alcohol.* 

Spearmint. 

Sassafras. 
Chloroform.* 

Ether.* 

PIPER— U.S.P. 
(Black  Pepper.) 

Black  pepper  is  the  unripe  fruit  of  Piper  nigrum,  a  climbing  vine 
cultivated  in  the  East  Indies.  It  contains  a  crystalline  neutral 
principle,  piperin,  a  volatile  oil,  and  a  pungent  resin.  The  average 
dose  of  ground  pepper  is  8  gr.  (0.5  Gm.). 

The  only  oflacial  preparation  foUows: 

Oleoresina  Piperis,  U.S.P.     Dose,  J-^-2  min.  (0.03-0.1  mil). 
Pepper  is  a  carminative  and  is  largely  used  as  a  condiment. 

MYRISTICA— U.S.P. 

(Nutmeg.) 

Nutmeg  is  the  seed  of  Myristica  fragrans,  an  evergreen  tree  grow- 
ing in  the  Molucca  Islands  and  other  East  India  islands.     It  con- 


238  CARMINATWES 

tains  a  volatile  oil,  to  which  its  aromatic  properties  are  due,  also  a 
fixed  oil.  The  average  dose  is  8  gr.  (0.5  Gm.)-  The  volatile  oil  is 
official. 

Oleum  Myristicse,  U.S.P.     Dase,  1-5  rain.  (0.06-0.3  mil). 
Nutmeg  is  used  as  a  condiment.     It  also  enters  as  an  aromatic 
into  many  of  the  official  aromatic  and  compound  preparations. 

Mace  is  the  ground  fleshy  covering  (arillode)  of  nutmeg.  It  is 
used  as  a  condiment. 

ZINGIBER— U.S.P. 

(Ginger.) 

Ginger  is  the  ground  rhizome  of  Zingiber  officinale,  a  perennial 
herb  which  grows  in  tropical  countries.  It  contains  a  volatile  oil, 
having  the  odor  of  ginger,  p,nd  a  viscid  resinous  principle,  having  a 
hot,  pungent  taste.     The  average  dose  is  15  gr.  (i.o  Gm.). 

The  following  preparations  are  official: 

Tinctura  Zingiberis,  U.S.P.     Dose,  20-60  min.  (1.3-4.0  mils). 

Fluidextractum  Zingiberis,  U.S.P.     Dose,  10-30  min.  (0.6-2.0 

mils). 

Syrupus  Zingiberis,  U.S.P.     Dose,  ^-4  fl.  dr.  (2.0-15.0  mils). 

Oleoresina  Zingiberis,  U.S.P.     Dose,  }i-2  min.  (0.03-0.13  mil). 

Ginger  is  used  as  a  carminative  and  as  a  flavoring  agent.  It  is 
also  a  constituent  of  the  official  compound  powder  of  rhubarb, 
aromatic  powder,  and  aromatic  fluid  extract. 

MENTHA  VmrDIS— U.S.P. 

(Spearmint.) 

Spearmint  is  the  leaves  and  tops  of  Mentha  spicata,  a  perennial 
herb  growing  wild  in  the  woods  and  along  the  roadsides  of  Europe 
and  North  America.     Its  official  preparations  are: 

Oleum  MenthaeViridis,  U.S.P.     Dose,  1-5  min.  (0.06-0.3  mil). 

Spiritus  Menthae  Viridis,  U.S.P.     Dose,  10-30  min.  (0.6-2.0 

mUs). 

Aqua  Menthae  Viridis,  U.S.P.     Dose,    1-4   fl.   dr.    (4.0-15.0 

mils). 

Therapeutically,  spearmint  is  almost  equivalent  to  peppermint, 
and  is  used  for  practically  the  same  purpose. 

CARDAMOMI  SEMEN— U.S.P. 

(Cardamom  Seed.) 

Cardamom  seed  is  the  dried  seed  of  Elettaria  Cardamomum,  a 
perennial  herb,  cultivated  in  the  mountainous  portions  of  India. 


ANISUM SASSAFRAS  239 

Its  active  principle  is  a  volatile  oil,  of  which  it  contains  about  5 
per  cent.     The  official  preparations  are: 

Tinctura  Cardamomi,  U.S. P.  Dose,  1-2  fl.  dr.  (4.0-8.0 
mils). 

Tinctura  Cardamomi  Composita,  U.S. P.  (contains  also  Cin- 
namon, Caraway,  Cochineal,  and  Glycerin).  Dose,  1-2  fl. 
dr.  (4.0-8.0  mils). 

Pulvis  Aromaticus,  U.S. P.  Aromatic  Powder  (contains  Car- 
damom Seed,  Ginger,  Cinnamon,  and  Nutmeg).  Dose, 
10-30  gr.  (0.6-2.0  Gm.). 

Cardamom  seed  also  enters  into  several  of  the  official  aromatic 
and  compound  preparations.  It  is  used  as  a  flavoring  agent  and 
carminative. 

ANISUM— U.S.P. 

(Anise.) 

Anise  is  the  small  fruit  of  Pimpinella  Anisum,  a  small  plant 
cultivated  in  Southern  Europe  and  North  America.  It  contains  a 
volatile  oil,  having  the  characteristic  odor  of  the  drug,  and  a  sweetish, 
aromatic  taste.     Its  preparations  follow: 

Oleum  Anici,  U.S. P.     Dose,  2-5  min.  (0.13-0.3  mU). 
Spiritus  Anici,  U.S. P.     Dose,  1-2  fl.  dr.  (4.0-8.0  mils). 
Aqua  Anici,  U.S. P.     Dose,  2-8  fl.  dr.  (8.0-30.0  mUs). 

The  drug  also  enters  into  many  of  the  official  aromatic  and  com- 
pound preparations.     It  is  used  chiefly  as  a  flavoring  agent. 

PIMENTA  (Nonofficial) 

(Allspice.) 

Allspice  is  the  nearly  ripe  fruit  of  Pimenta  officinalis,  an  evergreen 
tree  growing  in  the  West  Indies  and  South  America.  It  contains 
a  volatile  oil,  the  active  constituent  of  which  is  eugenol.  The  oil 
only  is  official,  and  is  a  constituent  of  spirit  myrica,  or  bay-rum. 

Oleum  Pimentse,  U.S. P.     Dose,  1-5  min.  (0.06-0.3  mil). 

SASSAFRAS— U.S.P. 

Sassafras  is  the  bark  of  the  root  of  Sassafras  variijolium,  a  shrubby 
tree  growing  in  the  eastern  and  central  parts  of  North  America. 
The  pith  was  formerly  official  {Sassafras  medulla,  U.S. P.  VIII). 
It  contains  an  aromatic,  fragrant,  volatile  oil  and  taijnic  acid. 

The  official  preparation  is : 


240 


FLAVORING    AGENTS 


Oleum  Sassafras,  U.S. P.  Dose,  1-5  min.  (0.06-0.3  mil). 
Mucilago  Sassafras  Medallae,  U.S. P.  VIII  (2  per  cent.). 
Dose,  1-8  fl.  dr.  (4.0-30.0  mils). 

Sassafras  oil  also  enters  into  the  official  compound  fluid  extract 
of  sarsaparilla  and  compound  syrup  of  sarsaparilla.  The  mucilage 
is  an  excellent  demulcent  in  cases  of  drug  poisoning,  and  a  tea  made 
by  steeping  the  bark  of  the  root  is  extensively  used  by  the  lay 
American  as  a  "spring  tonic." 

CARUM— U.S.P. 

(Caraway.) 

Caraway  is  the  fruit  of  Carum  Card,  a  native  herb  of  Asia,  but 
cultivated  in  Europe  and  North  America.     Its  active  constituent  is 

a  volatile  oil.  Caraway  is  used  as  a  flavoring  agent,  and  as  such 
it  enters  into  the  official  compound  tincture  of  cardamom  and 
compound  spirit  of  juniper.     The  oil  is  official: 

Oleum  Cari,  U.S. P.     Dose,  1-5  min.  (0.06-0.3  mil). 

FCENICULUM— U.S.P. 
(Fennel.) 

Fennel  is  the  fruit  of  Fceniciilum  vulgare,  a  plant  growing  chiefly 
in  Southern  Europe.  It  contains  an  aromatic  oil.  The  official 
preparations  are: 

Oleum  Foeniculi,  U.S. P.     Dose,  1-5  min.  (0.06-0.3  mil). 

Aqua  Fceniculi,  U.S. P.     Dose,  1-8  fl.  dr.  (4.0-30.0  mils). 
As  a  flavoring  agent  fennel  enters  into  compound  licorice  powder, 
compound  spirit  of  juniper,  and  compound  infusion  of  senna. 

CORIANDRUM— U.S.P. 

(Coriander.) 

Coriander  is  the  fruit  of  Coriandrum  sativum,  an  herb  grown  in 
all  parts  of  Europe  and  the  United  States.  It  contains  a  volatile 
oil,  which  is  official. 

Oleum  Coriandri,  U.S.P.     Dose,  1-5  min.  (0.06-0.3  niH)- 

The  oil  is  used  as  a  flavoring  agent,  and  as  such  it  enters  into  the 
syrup  of  senna  and  compound  spirit  of  orange. 

FLAVORING  AGENTS 

Flavoring  agents  are  used  to  mask  the  taste  of  nauseous  drugs, 
to  flavor  foods,  drinks,  etc.     The  chief  flavoring  agents  are: 


L IMON — AURANTIUM 

Lemon. 

Rose.  ' 

Orange. 

Sugar  and.  Sugar  of  Milk. 

Vanilla. 

Honey.  * 

Lavender. 

Saccharin. 

Sarsaparilla.  * 

Glucose. 

Persio  (Cudbear). 

LIMON  (Nonofficial) 

(Lemon.) 

241 


Lemon  is  the  ripe  fruit  of  Citrus  medica  Limonum,  a  tree  culti- 
vated in  most  semitropical  countries.  The  rind  contains  a  volatile 
oil,  and  the  juice,  citric  acid.     The  following  preparations  are  ofi&cial: 

Limonis  Cortex,  U.S. P.  (Fresh  Rind). 

Limonis    Succus,    U.S. P.    VIII   (Juice).     Dose,    1-4   fl.    oz. 

(30.0-120.0  mils). 

Tinctura  Limonis  Corticis,  U.S. P.     Dose,  >^-i  fl.  dr.  (2.0- 

4.0  mils). 

Oleum  Limonis,  U.S. P.     Dose,  1-5  min.  (0.06-0.3  nail). 

Acidum  Citricum,  U.S. P.     Dose,  5-20  gr.  (0.3-1.3  Gm.). 

Syrupus  Acidi  Citrici,  U.S. P.  (i  per  cent.).     Dose,  1-4  fl.  dr. 

(4.0-15.0  mils). 

The  oil  also  enters  into  other  official  preparations  as  a  flavoring 
agent.  Lemon  juice  has  been  used  in  scurvy,  both  as  a  preventive 
and  curative  agent.  In  the  form  of  cold  lemonade  it  makes  a  pleas- 
ant refrigerant  drink.  Hot  lemonade  is  a  useful  remedy  for  colds. 
Both  the  fresh  rind  and  juice  are  used  extensively  as  flavoring  agents. 

AURANTIUM  (Nonofficial) 
(Orange.) 

There  are  two  varieties  of  orange :  Sweet  orange,  Citrus  auran- 
tium,  and  bitter  orange.  Citrus  vulgaris.  The  following  preparations 
are  official: 

Aurantii  Amari  Cortex, U.S. P.  Dose,  15-30  gr.  (1.0-2.0  Gm.). 
Fluidextractum  Aurantii  Amari,  U.S. P.  Dose,  }i-i  fl.  dr. 
(2.0-4.0  mils). 

Tinctura  Aurantii  Amari,  U.S. P.  Dose,  1-2  fl.  dr.  (4.0-8.0 
mils). 

Aqua  Aurantii  Florum,  U.S. P.     Dose,  indefinite. 
Aqua  Aurantii  Florum  Fortior,  U.S. P. 
Syrupus  Aurantii  Florum,  U.S. P.     Dose,  indefinite. 
Auranti  Dulcis  Cortex,  U.S. P.     Dose,  15-30  gr.  (1.0-2.0  Gm.). 
Tinctura  Aurantii   Dulcis,  U.S. P.     Dose,  1-2  fl.  dr.  (4.0-8.0 
mils). 
16 


242  FLAVORING   AGENTS 

Syrupus  Aurantii,  U.S.P.     Dose,  indefinite. 

Oleum  Aurantii   Cortex,   U.S.P.     Dose,    1-5  min.  (0.06-0.3 

mils). 

Syrupus    Aurantii    Compositus,    U.S.P.     Dos6,    1-4    fl.    dr. 

(4.0-15.0  mils). 

Elixir  Aromaticum,  U.S.P.     Dose,  1-4  fl.  dr.  (4.0-15.0  mils). 

Both  varieties  of  orange  are  used  almost  exclusively  as  flavoring 
agents. 

VANILLA  (Nonofficial)    ^■ 

Vanilla  is  the  fruit  of  Vanilla  planifolia,  a  perennial  climbing 
plant,  native  of  the  West  Indies  and  tropical  America.  Its  charac- 
teristic odorous  principle  is  vanillin.     The  tincture  was  official: 

Tinctura  Vanillas,  U.S.P.  VIII  (10  per  cent.).     Dose,  a  few 
minims,  according  to  the  strength  of  flavor  desired. 

Vanilla  is  employed  chiefly  as  a  perfume  and  as  a  flavoring  agent. 


LAVANDULA  (Nonofficial) 
(Lavender.) 

Lavender  is  the  flowers  of  Lavandula  officinalis,  a  native  shrub  of 
Southern  Europe.  It  contains  a  fragrant  volatile  oil,  tannic  acid, 
and  resin.     The  official  preparations  are: 

Oleum  Lavandulae  Florum,  U.S.P.     Dose,  1-5  min.  (0.06-0.3 

mil). 

Spiritus  Lavandulae,  U.S.P.     Dose,  }4-i  fl.  dr.  (2.0-4.0  mils). 

Tinctura  Lavandulae  Composita,  U.S.P.     Dose,  H-i  fl.  dr. 

(2.0-4.0  mUs). 

The  compound  tincture  is  also  an  ingredient  of  Fowler's  solution. 
The  preparations  of  the  drug  are  used  only  for  their  agreeable  flavor. 

ROSA  GALLICA— U.S.P. 

(Red  Rose.) 

Red  rose  is  the  dried  petals  of  Rosa  gallica,  a  species  of  red  rose 
cultivated  extensively  in  Western  Asia  and  Southern  Europe.  It 
contains  a  volatile  oil,  tannic  acid,  sugar,  and  mucilage.  The  for- 
merly official  oil  of  rose  is  distilled  from  the  fresh  flowers  of  the 
Damascus  rose  {Rosa  damascena.)  The  following  are  its  official 
preparations : 


SACCHARUM — BENZOSULPHINIDUM  243 

Fluidextractum  Rosae,  U.S. P. 

Mel  Rosae,  U.S. P.  (12.5  per  cent,  of  the  fluid  extract  in  clari- 
fied Honey). 

Aqua    Rosae   Fortior,  U.S. P.  (Water  saturated  with  Oil   of 
Rose). 

Aqua  Rosae,  U.S. P.  (equal  parts  of  Stronger  Rose  Water  and 
Distilled  Water). 

Preparations  of  rose  also  enter  into  several  official  preparations 
as  flavoring  agents.  The  ointment  of  rose  water  (cold  cream)  makes 
an  excellent  application  for  the  hands  and  face.  A  splendid 
lotion  for  the  hands  is:  Phenol  (95  per  cent.)  6  min.  (0.36  mil); 
borax,  14.  dr  (2.0  gm.);  rose  water  and  glycerin,  of  each  i3^  fi.  oz. 
(45.0  mils). 

SACCHARUM— U.S.P.   AND   SACCHARUM   LACTIS— U.S.P. 

(Cane-sugar;  Sugar  and  Sugar  of  Milk;  Lactose.) 

Cane-sugar  is  refined  from  sugar-cane,  Saccharum  officinarum, 
from  various  species  of  broom-corn,  Sorghum,  and  from  one  or  more 
varieties  of  sugar-beet,  Beta  vulgaris.  A  saturated  solution  is  official 
as: 

Syrupus,  U.S.P.  (Simple  Syrup). 

Sugar  enters  as  a  flavoring  agent,  preservative,  vehicle,  or  excipi- 
ent  into  many  official  compound  preparations.  Sugar  of  milk  is  the 
sugar  obtained  from  the  whey  of  cow's  milk.  It  is  harder,  less  solu- 
ble, and  less  sweet  than  ordinary  sugar,  and  is  largely  used  as  a 
diluent  for  powders,  as  in  Dover's  powder. 

BENZOSULPHINIDUM— U.S.P. 

(Benzosulphinid;  Saccharin) 

Saccharin  is  obtained  from  the  coal-tar  derivative,  toluene.  It 
occurs  in  a  light,  white,  crystalline  powder,  is  odorless,  and  possesses 
500  times  the  sweetening  power  of  cane-sugar.  It  is  soluble  in  290 
parts  of  water,  more  so  in  alcohol  or  glycerin,  and  readily  soluble  in 
alkaline  solutions. 

Saccharin  is  used  as  a  flavoring  agent  for  mouth-washes,  tooth- 
pastes, tooth-powders,  etc.  Internally,  in  large  doses,  it  retards 
digestion  and,  therefore,  metabolism.  The  average  dose  is  3  gr. 
(0.2  Gm.). 


244  FLAVORING   AGENTS 

GLLXOSUM— U.S.P. 

(Glucose;  Syrupy  Glucose.) 

Glucose  is  a  product  obtained  by  the  incomplete  hydrolysis  of 
starch,  and  consists  chiefly  of  dextrose  and  dextrins.  It  is  a  colorless 
or  slightly  colored,  thick,  syrupy  liquid;  odorless  and  has  a  sweet 
taste;  freely  soluble  in  water,  and  sparingly  soluble  in  alcohol. 
Glucose  is  used  as  a  flavoring  agent;  but  should  not  enter  as  such 
into  dentifrices,  as  it  is  a  fermentable  sugar  and  its  fermentation  in 
the  mouth  produces  the  acid  (lactic)  which  causes  caries  of  the  teeth. 

PERSIO  (Nonofficial) 
(Cudbear.) 

Cudbear  occurs  as  a  purplish-red  powder  prepared  from  species 
of  Rocella  De  Candolle,  or  other  lichens.  The  drug  is  not  used  as  a 
flavoring  agent,  but  solutions  of  it  are  employed  extensively  for 
coloring  purposes.  An  aqueous  or  alcoholic  preparation  of  cudbear 
is  of  a  deep  red  color  which  is  rendered  lighter  in  tint  by  the  addition 
of  acids  and  changed  to  purplish  red  on  the  addition  of  alkalies. 
There  are  no  oflacial  preparations,  but  the  National  Formulary  gives 
directions  for  the  preparation  of  a  tincture  and  compound  tincture  of 
cudbear.  These  are  the  preparations  used  for  coloring  solutions  of 
various  kinds  (mouth- washes,  etc.),  as  well  as  the  powdered  cudbear 
itself. 


BIOLOGIC  PRODUCTS 

The  advanced  therapy  of  many  infectious  diseases  includes  the 
intelligent  use  of  biologic  products.  Many  of  the  systemic  diseases 
of  this  character  are  known  to  have  a  direct  relation  to  diseased 
mouth  and  throat  conditions  (teeth  and  tonsils).  It  is,  therefore, 
important  that  the  student  and  practitioner  of  dentistry  understand 
the  principles  upon  which  this  therapy  is  based;  and  be  familiar 
with  the  nature  and  character,  as  well  as  the  indications  and  uses 
of  the  products  obtained  from  Biologic  Laboratories. 

An  infectious  disease  is  one  caused  by  the  invasion  of  micro- 
organisms into  the  tissues  of  an  animal  (or  plant).  The  invading 
germ  gains  admission  into  the  body  and  tissues  in  various  ways; 
through  the  air  into  the  respiratory  passages  (mouth,  nose,  throat 
and  lungs) ;  through  food  and  water  into  the  digestive  tract  (stomach 
and  intestines) ;  through  cuts  and  abrasions  of  the  skin  and  mucous 
membranes  (inflamed  and  bleeding  gums) ;  through  the  canals  of 
pulpless  teeth;  and  through  direct  injection  into  the  blood  stream. 

When  these  bacteria  have  thus  gained  entrance  into  the  tissues, 
where  they  find  the  proper  food,  moisture  and  temperature  neces- 
sary to  their  growth,  they  multiply  and  proliferate  rapidly;  and  dur- 
ing this  growth  they  produce  substances  known  as  Toxins,  which 
are  poisons  to  the  tissues  of  the  body.  Sometimes  these  poisons 
remain  largely  within  the  cell  body  of  the  bacteria  and  are  given  o2 
at  the  death  of  the  germ.  Such  poisons  are  called  intracellular 
toxins.  An  example  is  the  staphylococcus  pyogenes  aureus,  the  germ 
which  causes  boils.  In  other  instances  the  poisons  are  excreted  by  the 
bacteria  into  the  tissues  or  blood  stream  and  may  be  thus  carried  to 
various  parts  of  the  body,  attacking  those  parts  which  are  subnormal 
and  have  the  least  resistance.  Poisons  of  this  kind  are  called 
extracellular  toxins.  Examples  of  such  germs  are  the  bacillus  diph- 
theria and  bacillus  tetani,  which  cause,  respectively,  diphtheria  and 
tetanus  (lock-jaw).  The  streptococcus  viridans  also  belongs  to  this 
class  of  germs,  and  is  of  special  interest  to  dentists  for  the  reason 
that  the  poisons  are  elaborated  in  pyorrheal  pockets  about  the  teeth 
and  in  dental  granulomas  and  den  to-alveolar  abscesses  in  the  periapical 
region.  The  poisons  being  of  the  extracellular  variety  are  continually 
formed  and  constantly  charging  the  blood  stream  as  long  as  the  infec- 

245 


246  BIOLOGIC    PRODUCTS 

tion  in  these  areas  is  present.  Thus  may  follow  diseases  of  the 
joints  (arthritis),  heart  (endocarditis),  kidneys  (nephritis),  etc. 
It  will  be  observed  then  how  absolutely  essential-  it  is  for  the  dentist 
to  eradicate  all  infections  about  the  teeth. 

Nature  is  constantly  on  the  alert  to  protect  the  body  against  the 
invasion  of  these  germs  and  their  poisons.  Stimulated  by  the 
bacterial  toxins,  the  body  tissues  react  and  produce  substances 
known  as  Antitoxins  and  Antibodies.  The  antitoxins  are  chemic 
substances  which  destroy  the  poisonous  nature  of  the  toxins.  The 
antibodies  are  substances  which  antagonize  the  bacteria  themselves, 
actually  kilUng  and  destro3dng  them,  or  preventing  their  growth  and 
proHferation. 

The  manufacture  and  use  of  biologic  products  are  based  upon 
these  principles;  and,  before  considering  the  subject  further,  it  is 
well  that  the  student  should  understand  what  is  meant  by  the  term 
Immtinity.  This  is  recognized  as  the  ability  or  power  which  enables 
certain  individuals  to  resist  disease.  There  are  two  kinds  of  im- 
munity— natural  and  acquired.  Natural  immunity  is  that  which 
exists  in  a  normal,  healthy  animal  or  human  body.  In  this  case 
the  tissues  of  such  bodies  contain  or  produce  substances  which  are 
antagonistic  to  the  pathologic  bacteria.  Hence  these  germs  cannot 
grow  in  the  body  and  no  disease  results.  Acquired  immunity  is 
the  resistance  to  a  disease  which  exists  either  after  an  attack  of  that 
disease,  or  after  inoculation  with  some  specific  culture,  vaccine, 
antitoxin  or  serum.  An  example  of  the  first  is  a  person  who  Jias  had 
smallpox ;  an  example  of  the  second  is  a  person  who  has  been  vacci- 
nated with  smallpox  virus — both  are  immune  to  smallpox,  and  the 
immunity  has  been  acquired. 

This  brings  us  to  a  discussion  of  biologic  products,  which  may  be 
divided  into  at  least  three  general  classes — Antitoxins,  Serums  and 
Vaccines. 

ANTITOXINS 

Antitoxins  are  among  the  simplest  and  most  useful  of  the  anti- 
bodies. As  the  name  implies,  they  antagonize  toxins.  Though 
toxins  may  be  excreted  by  plants  other  than  the  bacteria  and  some 
animals,  e.g.,  in  snake  venoms,  the  typical  toxins  are  the  soluble 
poisons  thrown  ofif  by  diphtheria  and  tetanus  bacilli. 

Diphtheria  and  tetanus  are  dangerous  diseases  almost  entirely 
because  of  the  action  of  these  toxins  and,  conversely,  their  pre- 
vention and  cure,  when  the  organisms  have  once  gained  entrance 
to  the  body,  depends  on  the  work  of  the    particular    antitoxin. 


SERUMS  ■  247 

Though  the  presence  of  the  toxin  stimulates  the  body  to  produce 
antitoxin,  this  active  immunity  may  not  be  enough  to  save  Hfe;  and, 
at  any  rate,  assistance  by  the  injection  of  antitoxin,  ready  made  in 
the  blood-serum  of  another  animal,  hastens  the  cure  or  may  prevent 
the  disease. 

The  antitoxins  for  both  diphtheria  and  tetanus  are  official: 
Serum  Antidiphthericum,  U.S. P.  and  Serum  Antitetanicum, 
U.S. P.  These  antitoxins  are  obtained  from  the  coagulated  blood 
of  the  horse,  or  other  large  domestic  animal  which  has  been  properly 
immunized  against  the  toxin  produced  by  the  germ  ca,using  the 
disease.  Diphtheria  and  tetanus  are  not  dental  diseases,  nor  have 
they  any  direct  relation  to  diseased  mouth  conditions ;  therefore,  the 
dentist  will  not  be  called  upon  to  administer  the  commercial  anti- 
toxins prepared  for  these  diseases. 

SERUMS 

Serums  are  more  complex  in  action  and  much  less  satisfactory 
for  therapeutic  purposes  than  are  the  antitoxins.  With  these 
products  the  contained  antibodies  are  expected  to  resist  the  bacteria 
themselves — not  simply  neutraHze  their  toxins,  as  is  the  case  with 
antitoxins.  In  the  manufacture  of  serums  proper,  horses  are  im- 
munized by  inoculation  first,  with  dead  cultures,  and,  secondarily, 
with  increasing  doses  of  living  culture  of  the  specific  bacteria,  until 
their  blood  contains  substances  that  directly  or  indirectly  destroy 
either  Ihe  life  or  the  activity  of  these  specific  bacteria.  The  sub- 
stances in  the  immune  serum  that  destroy  the  hfe  or  the  activity 
of  the  specific  germ  are  collectively  spoken  of  as  antibodies.  They 
have  never  been  isolated  as  specific  chemic  substances,  but  their 
presence  in  the  serum  is  assumed  from  their  definite  efl'ects  on  bac- 
teria. The  names  given  to  the  more  important  of  these  antibodies 
are  baderiolysins,  bacteriotropins,  opsonins  and  agglutinins.  Of  these 
antibacterial  substances,  the  bacteriolysins  are  those  which  both 
kill  and  dissolve  the  bacteria,  and  are  considered  to  be  the  anti- 
bacterial bodies  proper.  For  example,  take  a  serum  from  an 
animal  immunized  against  the  streptococcus  germ,  and  put  into 
it  some  Uving  streptococci;  after  a  brief  period  of  incubation,  an 
examination  will  show  that  the  streptococci  are  not  only  killed  but 
have  been  dissolved  as  well.     This  phenomenon  is  called  bacteriolysis. 

Aside  from  the  direct  killing  01  cne  Dactena  oy  the  blood  serum, 
the  invaders  may  be  taken  up  by  the  leukocytes — though  not,  as  a 
rule,  until  they  have  been  acted  upon  by  other  substances  in  the 


248  BIOLOGIC    PRODUCTS 

serum,  mentioned  above  as  bacteriotropins  and  opsonins,  according 
to  whether  they  resist  moderate  heat  or  not. 

The  agglutinins  are  antibodies  which  act  directly,  causing  the 
bacteria  to  gather  in  clumps.  They  are  valuable  in  diagnosis  on 
account  of  their  specificity,  but  probably  have  no  important  action 
in  protecting  the  human  organism  from  an  infection. 

Among  the  more  important  antibacterial  serums  may  be  men- 
tioned antistreptococcus  serum,  antistaphylococcus  serum,  and  Guti- 
pneumococcus  serum. 

VACCINES 

Vaccines  or  bacterins  are  suspensions  of  killed  bacteria  in 
physiologic  salt  solution,  usually  with  the  addition  of  some  preserva- 
tive such  as  0.4  per  cent,  of  cresol  (tricresol)  or  0.5  per  cent,  of  phenol. 
An  autogenous  vaccine  is  one  made  from  the  bacteria  infecting  the 
person  immunized.  A  stock  vaccine  is  one  made  from  standard 
cultures  of  the  germ.  A  mixed  vaccine  is  one  prepared  from  more 
than  one  species  of  bacteria. 

The  use  of  bacterial  vaccines  is  associated  with  the  development 
of  the  opsonic  theory;  but  it  is  claimed  by  those  in  authority  that 
the  opsonic  index  as  a  measure  of  immunity  is  open  to  question. 
It  may  be  said  that  bacterial  vaccines  are  of  particular  value  in 
locaHzed  affections,  especially  those  due  to  infection  by  the  staphy- 
lococcus and  streptococcus  germs.  Dental  literature  to-day  is 
replete  with  articles  on  the  relation  of  focal  infection  to  systemic 
disease.  It  has  been  definitely  shown  by  Murphy,  Billings,  Rose- 
now,  Rhein,  Grieves,  Hartzell,  Price,  and  others  that  infections 
about  the  teeth,  especially  from  dental  granulomas  and  dento- 
alveolar  abscesses,  may  result  in  systemic  diseases  involving  the 
joints,  heart,  kidneys,  stomach,  and  other  tissues  and  organs.  By 
a  series  of  experiments,  Gilmer,  Moody,  and  others,  have  found 
that  the  predominating  organism  in  conditions  resulting  from  a 
gangrenous  pulp,  therefore  the  group  active  in  bringing  about  the 
decomposition,  is  a  streptococcus.  The  use  of  antistreptococcus 
vaccines  in  the  treatment  of  chronic  arthritis  and  other  ajffections 
resulting  from  a  streptococcus  infection  about  the  teeth  or  tonsils 
has  been  reported  by  various  authorities  as  affording  much  relief 
and  in  many  cases  effecting  a  permanent  cure.  It  is  understood 
that  eradication  of  the  foci  of  infection  is  of  the  first  and  prime 
importance. 

Among  the  more  important  bacterial  vaccines  may  be  mentioned 
streptococcus  vaccine,  typhoid  vaccine,  and  smallpox  vaccine. 


REMEDIES  OTHER  THAN  DRUGS  249 

In  the  discussion  of  biologic  products  and  their  uses,  the  author 
has  made  no  attempt  here  to  go  into  the  subject  in  detail.  He  has 
endeavored  to  give  only  the  principles  underlying  the  therapy,  which 
as  yet  is  more  or  less  speculative. 

REMEDIES  OTHER  THAN  DRUGS 

The  object  sought  in  all  therapeutics  is  simply  to  assist  Nature 
in  her  efforts  to  ward  off  disease  and  to  restore  an  abnormal  to  a 
normal  condition.  In  dental  therapeutics  this  gives  to  the  resource- 
ful dentist  a  wide  range  of  activity.  There  are  several  means  of 
combating  disease  other  than  by  the  use  of  drugs.  Those  deserving 
mention  will  briefly  be  discussed  here.     They  are: 


Heat. 

Electricity. 

Cold. 

Massage. 

Compressed  Air. 

Suction. 

Light. 

Suggestion. 

HEAT 

Heat  is  a  useful  therapeutic  agent.  It  is  largely  employed  locally 
in  dentistry,  and  is  utilized  in  both  the  dry  and  moist  forms.  Dry 
heat  is  applied  by  means  of  hot  cloths,  bran-bags,  water-bags  or  water- 
bottles,  or  superheated  dry  air.  Moist  heat  may  be  appKed  by  means 
of  fomentations,  poultices,  or  the  hot-water  s}Tinge.  Hot-water 
baths  are  also  applicable  to  certain  limited  portions  of  the  body,  as  the 
feet,  and  are  used  for  counterirritant  purposes.  Locally  applied,  heat 
allays  irritation  of  the  peripheral  sensory  nerves,  dilates  the  cutaneous 
vessels,  increases  perspiration,  and,  like  cold  and  counterirritation, 
doubtless  exerts  a  favorable  influence  on  the  subjacent  structures. 

The  general  application  of  heat  may  be  obtained  by  means  of 
the  hot-water  bath,  hot  pack,  hot-vapor  bath,  or  hot  blankets.  In 
the  Russian  bath  steam  replaces  the  hot-dry  air  of  the  Turkish  bath. 
The  first  effect  of  the  general  application  of  heat  is  free  perspiration 
from  dilatation  of  the  cutaneous  vessels. 

Moist  external  heat  is  used  for  a  variety  of  diseases,  especially 
subacute  and  chronic  rheumatism.  Dry  external  heat  may  be  em- 
ployed in  many  cases  of  drug  poisoning,  one  symptom  of  which  is 
the  characteristic  cold,  clammy  sweat. 

Moist  heat  is  used  locally  in  pericementitis,  in  acute  alveolar 
abscesses  accompanied  by  pain  and  swelling,  and  many  other  dental 
conditions.  Dry  heat  is  chiefly  used  in  dentistry  for  drying  tooth- 
structure  and  obtunding  sensitive  dentin.     For  this  purpose  many 


250  REMEDIES  OTHER  THAN  DRUGS 

apparatuses  have  been  devised  for  heating  dry  air.  For  root-canal 
work  properly-shaped  wire  may  be  heated  and  used. 

Heat  is  also  employed  to  the  extent  of  actual  destruction  of  tissue 
in  vesication  and  cauterization.  The  thermocautery  and  galvano- 
cautery  are  exceedingly  valuable  as  counterirritant,  revulsive,  and 
hemostatic  measures. 

Thennometric  Scale.— For  determining  the  temperature,  the 
Fahrenheit  scale  is  in  ordinary  use  in  America  and  England;  the 
Centigrade  is  used  on  the  European  Continent;  the  latter  scale  is 
also  largely  used  in  the  sciences.  The  freezing-point  of  water  with 
the  Fahrenheit  scale  is  32°  above  zero;  with  the  Centigrade  scale  it 
is  at  zero.  The  boiling  point  of  water  with  the  Fahrenheit  scale  is 
212°.  This  minus  the  32°  equals  180°  above  zero.  The  boiling- 
point  of  water  with  the  Centigrade  scale  is  100°.  Therefore,  stated 
in  terms  of  proportion:  ioo°C.  :i8o°F.  :;5  19,  hence  the  following 
simple  rules  for  converting  the  degrees  of  one  scale  into  the  other. 

To  Convert  Degrees  of  the  Fahrenheit  Scale  into  those  of  Centi- 
grade: If  the  temperature  be  above  the  freezing-point  (32°),  sub- 
tract 32;  if  it  be  below  the  freezing-point,  subtract  the  number  from 
32,  algebraically;  then  multiply  the  remainder  by  5  and  divide  by  9. 

To  Convert  Degrees  of  the  Centigrade  Scale  into  those  of  Fahren- 
heit: Multiply  the  number  of  the  former  by  9  and  divide  by  5; 
if  the  temperature  be  above  the  freezing-point  (0°),  add  32;  if  it  be 
below  the  freezing-point,  subtract  the  result  from  32,  algebraically. 

COLD 

Cold,  like  heat,  may  be  used  either  locally  or  generally  as  a  thera- 
peutic agent.  It  is  the  local  appHcation  of  the  remedy  with  which 
dentists  are  mostly  concerned.  It  may  be  locally  applied  by  means 
of  cloths  wrung  out  of  iced  water,  an  ice-bag,  an  ice-poultice,  etc. 
As  cold  is  but  a  lesser  degree  of  heat,  the  latter  may  be  abstracted 
and  cold  produced  by  spraj^ng  the  part  with  a  highly  volatile  liquid, 
like  ethyl  chlorid,  ether,  etc. 

Local  applications  of  cold  abstract  heat  from  the  part,  lessen  the 
sensibility  of  the  peripheral  nerve-endings,  cause  constriction  of  the 
blood-vessels  traversing  the  tissues  exposed  to  the  cold,  and  affect, 
reflexly,  the  vascularity  of  the  structures  subjacent  to  the  site  of 
application. 

The  general  application  of  cold  to  the  body  may  be  accomplished 
in  several  ways:  By  a  cold-water  bath,  cold  sponge-bath,  cold  pack,  or 
the  cold  douche.  When  followed  by  vigorous  rubbing  with  a  Turkish 
towel,  cold  bathing  exerts  a  powerful  tonic  effect.     It  sharpens  the 


COMPRESSED    AIR — LIGHT  25 1 

appetite,  aids  digestion,  promotes  metabolism,  and  greatly  favors 
the  elimination  of  waste  products. 

Cold  is  employed  for  a  variety  of  purposes  in  the  treatment  of 
disease.  In  dentistry  it  is  used  as  a  counterirritant  in  acute  alveolar 
abscess,  in  pericementitis,  neuralgia,  and  other  conditions.  As  a  re- 
frigerant local  anesthetic,  the  effect  of  cold  may  be  obtained  by 
using  ether,  combinations  containing  it,  or  ethyl  chlorid,  as  a  spray. 
In  this  manner  cold  is  used  in  lancing  abscesses,  obtunding  sensitive 
dentin,  extracting  loose  teeth,  etc. 

COMPRESSED  AIR 

Compressed  air  is  one  of  the  most  convenient  agents  in  the  mod- 
ern dental  office.  While  in  itself  it  may  not  be  considered  a  thera- 
peutic agent,  except  as  a  vehicle  for  applying  heat  or  cold,  it  is,  never- 
theless, a  valuable  adjunct  to  the  use  of  many  such  agents.  For 
drying  a  sensitive  cavity,  clearing  away  the  "  chips, ^^  and  lessening  the 
pain  of  drilling,  it  has  no  equal  (see  p.  286).  In  treating  pyorrhea 
alveolaris  it  serves  a  useful  purpose.  By  its  employment  the  pocket 
may  be  kept  dry  sufficiently  long  for  the  operator  to  see  in  many  cases 
whether  or  not  the  deposits  have  been  thoroughly  removed.  It  may 
be  used  as  the  force  for  spraying  solutions  all  through  the  operation ; 
and  when  the  teeth  are  scaled  and  polished  the  field  may  be  kept  dry 
by  the  use  of  compressed  air  while  the  astringent  remedy  is  applied. 
The  resourceful  dentist  will  find  many  uses  for  this  agent. 

LIGHT 

Light  is  a  form  of  energy  which  has  recently  been  brought  forth 
as  having  a  peculiarly  favorable  effect  upon  diseased  tissues  of  the 
body,  and  is  employed  to-day  for  a  variety  of  purposes  in  therapeu- 
tics, both  general  and  dental.  The  blue  light,  lucodescent  light,  and 
other  forms  are  used.  The  mode  of  action  is  not  well  understood. 
Extravagant  claims  are  being  made  for  the  lucodescent  light,  but  it  is 
thought  by  many  that  its  real  virtue  lies  in  the  soft  penetrating  heat 
produced.  It  may  prove  to  be  a  practical  means  of  applying  heat, 
which  has  long  been  recognized  as  a  therapeutic  agent.  Reliable 
evidence  has  thus  far  been  lacking  to  prove  that  Hght  has  an  ac- 
tion upon  the  tissues  other  than  through  the  heat  generated.  The 
blue  hght  has  been  suggested  for  obtunding  sensitive  dentin,  and  is  ob- 
tained in  one  way  by  passing  the  ray  through  blue  glass.  A  blue  bulb 
(16  or  32  c.  p.)  is  used  on  an  ordinary  electric  socket.  The  room  is  dark- 
ened and  the  patient  requested  to  look  at  the  light  which  is  held  from 


252  REMEDIES    OTHER   THAN   DRUGS 

6  in.  to  I  ft.  from  the  eyes.  Whether  the  Ught  acts  locally  or 
affects  the  vision  and  thus  the  general  nervous  system  has  yet  to 
be  determined.  The  author's  experience  with  light  thus  far  has  not 
been  encouraging.  It  is  true,  however,  that  light  differs  in  effect 
from  heat,  though  both  come  from  the  same  heated  body.  This 
phenomenon  is  observed  in  the  action  of  Hght  on  certain  chemicals; 
for  example,  the  silver  salts  undergo  a  chemic  change  when  exposed 
to  sunHght  or  luminously  hot  bodies.  For  this  reason  Black  and 
others  have  suggested  that  the  tooth-surface  treated  with  silver 
nitrate  be  exposed  to  the  sunlight,  if  possible.  The  author  finds  a 
more  practical  way  of  accomplishing  the  change  in  the  decomposition 
of  the  salt  by  using  the  small  electric  mouth-lamp.  Light  from  a 
small  electric  mouth-lamp  serves  almost  as  a  positive  means  of  diag- 
nosing a  dead  pulp  in  a  tooth  where  the  color  is  practically  normal; 
it  also  aids  materially  in  confirming  the  diagnosis  of  obscure  antrum 
involvement. 

Carrel,  Crile,  and  others,  advocated  the  use  of  light  or  heat  from 
an  electric  lamp  in  the  treatment  of  injected  wounds.  It  is  to  be 
hoped  that  further  investigation  may  be  made  with  Hght  as  a  thera- 
peutic agent  that  its  action  may  be  better  understood,  for  it  seems  to 
possess  sufl&cient  merit  to  justify  such  investigation. 

Rontgen  or  X-ray. — The  Rontgen  or  X-ray  has  been  employed 
extensively  in  both  general  and  dental  therapeutics;  in  dentistry  it 
is  largely  used  for  diagnostic  purposes.  By  means  of  the  radiograph 
(an  X-ray  picture)  the  diagnosis  of  the  following  conditions  may  be 
confirmed: 

1.  Fracture  of  the  jaw  and  the  relation  of  the  fragments. 

2.  Fracture  and  dislocation  of  the  teeth  in  the  jaw. 

3.  Alveolar  abscess:  involving  more  roots  than  one;  in  relation  to 
the  nasal  cavity ;  in  relation  to  the  maxillary  antrum  (antrum  of  High- 
more). 

4.  Impacted  and  nonerupted  teeth;  the  cause  of  neuralgic  conditions, 
and  in  point  of  treatment,  extraction,  etc. 

5.  Pulp-nodules,  pulp-calcification,  and  secondary  dentin. 

6.  Cementosis. 

7.  Foreign  bodies  in  the  maxillary  antrum. 

8.  Broken  broach  in  tooth-root. 

There  are  other  conditions  in  dental  practice  wherein  the  X-ray 
aids  materially  in  arriving  at  a  correct  diagnosis.  Much  credit  is 
due  to  Kells,  Price,  Shamburg,  Lewis,  Raper,  and  others  for  develop- 
ing radiography  in  dentistry. 

The  X-ray  treatment  has  been  found  extremely  valuable  in  super' 


ELECTRICITY  253 

jicial  cancer,  lupus  vulgaris,  and  acne.  It  has  also  been  employed  in 
the  treatment  of  pyorrhea  alveolaris  with  varying  results.  The 
powerful  actinic  properties  of  this  modified  form  of  light  are  illus- 
trated by  the  fact  that  several  deaths  and  many  injuries,  such  as 
burns,  necessitating  amputation  in  some  cases,  have  be^n  traced  to 
long-continued  exposure  to  the  X-ray. 

The  method  devised  by  Finsen  of  concentrating  rays  of  either 
sunHght  or  electric  arc-light  has  met  with  more  or  less  success  in  the 
treatment  of  lupus  vulgaris  and  other  skin  diseases,  but  it  has  not 
been  utilized  in  dentistry  to  any  extent. 

Radium. — The  salts  of  radium  (bromid  and  chlorid)  give  out 
three  kinds  of  rays,  known  as  alpha,  beta,  and  gamma  rays.  The 
therapeutic  uses  of  radium  rays  have  been  shown  to  follow  practically 
the  same  lines  as  those  of  the  X-ray,  but  they  are  generally  considered 
less  useful.  At  the  present  time  the  use  of  radium  rays  is  only  in  the 
experimental  stage  and  no  positive  evidence  is  at  hand  to  prove  their 
superior  value.  They  require  the  same  careful  handhng  as  the  X-ray, 
as  they  are  capable  of  producing  severe  burns  and  even  deep-seated 
ulcers. 

ELECTRICITY 

Electricity  is  used  as  a  therapeutic  agent  in  itself,  as  well  as  a  carry- 
ing medium  for  drugs  (cataphoresis) ,  and  for  purposes  of  diagnosis 
and  prognosis.  Two  currents  are  employed,  the  primary,  or  galvanic, 
and  the  induced,  or  faradic,  the  battery  furnishing  the  current  being 
supplied  with  a  positive  pole,  or  anode,  and  a  negative  pole,  or  cathode. 
When  the  electric  current  is  passed  through  a  muscle  it  causes  con- 
traction of  the  latter.  As  a  muscle  degenerates  it  gradually  loses  its 
electrocontractility,  the  response  to  the  faradic  current  disappearing 
first,  while  the  galvanic  current  produces  contraction  for  some  time 
longer,  until  finally  no  current  will  produce  any  effect. 

Electricity  is  used  as  a  muscle  and  nerve  stimulant  for  a  variety 
of  conditions,  such  as  the  so-called  idiopathic  forms  of  neuralgia, 
in  neurasthenia,  hysteria,  etc.  In  poisoning  by  opium  and  other  nar- 
cotics a  strong  faradic  current  often  affords  a  means  of  arousing  the 
patient  without  increasing  the  exhaustion  or  causing  any  ill  effects. 
Electricity  affords  almost  a  positive  means  of  diagnosing  a  dead  pulp 
in  a  tooth.  The  suspected  tooth  is  tested  by  using  a  dry-cell  vibrat- 
ing coil,  which  will  be  explained  in  Practical  Therapeutics  (see  p.  338). 
In  dental  therapeutics,  perhaps,  the  greatest  use  of  electricity  has 
been  in  connection  with  a  method  of  treatment  called  cataphoresis. 


254  REMEDIES    OTHER    THAN   DRUGS 

Cataphoresis. — This  is  a  term  applied  to  the  process  of  carrying 
medicinal  agents  in  solution  into  the  various  tissues  and  organs  of  the 
body  by  means  of  the  electric  current.  It  is  used  chiefly  for  obtund- 
ing  sensitive  dentin  and  for  the  purpose  of  anesthetizing  the  pulp  to 
facilitate  its  painless  removal  (see  p.  324). 

MASSAGE 

Massage  is  a  term  used  to  designate  methodical  kneading,  rub- 
bing, and  percussion  of  the  body.  The  person  practising  massage 
is  known  as  a  masseur  (male)  or  masseuse  (female) .  The  efficacy  of 
proper  massage  in  many  pathologic  conditions  can  no  longer  be 
doubted.  It  acts  as  a  stimulant  to  both  nerve  and  muscle  and  to 
many  of  the  bodily  functions,  assisting  circulation  and  favoring  the 
elimination  of  waste-products.  Massage  is  employed  in  dentistry  for 
both  its  local  and  systemic  effects  in  neuralgia,  pyorrhea  aheolaris,  and 
edema  resulting  from  alveolar  abscess  and  other  conditions;  in  medicine 
it  is  used  in  rheumatism,  paralysis,  synovitis,  sprains,  and  fractures. 
In  the  "rest  cure"  of  Mitchell  it  is  combined  with  isolation,  rest, 
forced  feeding,  and  faradism.  It  is  also  used  for  its  general  effect 
in  neurasthenia,  nervous  prostration,  and  hysteria. 

SUCTION 

The  method  of  producing  h}T:eremia  in  a  part  by  means  of 
suction  for  the  purpose  of  combating  disease  is  fast  gaining  recogni- 
tion in  medicine,  and  it  has  been  employed  also,  to  some  extent, 
in  dentistry. 

When  some  noxious  influence  acts  on  a  more  or  less  limited  area 
of  the  body,  local  resistance  is  manifested  by  the  production  of  granu- 
lation tissue  and  of  hyperemia.  Under  favorable  circumstances  the 
granulation  tissue  repairs  defects  resulting  from  the  noxa,  or  more 
or  less  completely  encapsulates  the  irritating  agent.  Under  less 
favorable  circumstances,  the  irritation  being  continuous,  e.g.,  in 
tuberculous  infection,  granulomata  are  formed,  these  granulomata 
being  evidence  of  defense.  If  the  resisting  power  is  sufficient,  the 
embryonic  tissue  overcomes  the  irritant  and  incloses  it  in  fuUy  de- 
veloped scar  tissue.  Stimulation  of  the  production  of  granulation 
in  and  around  a  tuberculous  focus  seems  to  be  the  therapeutic  action 
of  injections  of  emulsions  containing  iodoform,  bismuth,  finely 
divided  carbon,  etc.,  and  of  sclerogenic  injections. 

The  second  method  by  which  Nature  resists  a  noxa  (or  infection) 
is  by  h}'peremia.     When  an  irritant,  e.g.,  the  staphylococcus,  gains 


SUGGESTION 


255 


access  to  the  tissues,  the  flow  of  blood  to  the  part  becomes  increased, 
there  is  exudation  of  fluids  and  leucocytes  from  the  vessels  into  the 
tissues.  The  blood  serum  contains  antibodies  or  antitoxins  which 
neutralize  the  chemic  products  of  bacterial  activity;  bacterial  agents 
which  attack  the  bacteria  themselves;  opsonins  which  prepare  the 
bacteria  for  absorption  and  destruction  by  phagocytes,  or  perhaps 
act  as  a  sort  of  appetizer  to  the  phagocytes,  and  lastly  there  are  the 
leucocytes  which  act  as  phagocytes,  directly  killing  bacteria  or,  as 
scavengers,  removing  the  debris  of  the  fight.  Thus,  while  the  granu- 
lation tissue  acts  as  a  sort  of  passive  role  besieging  the  invading 
irritant,  the  h3rperemia  directly  and  actively  combats  it  (Binnie).^ 

The  suction  method  of  producing  hyperemia  cannot  but  prove 
eflScacious  in  the  treatment  of  certain  forms  of  alveolar  abscess  and 
pyorrhea  alveolaris.  It  now  remains  for  some  ingenious  dentist  to 
devise  a  practical  appliance  by  which  dental  appHcations  can  be 
made,  and  much  good  will  surely  result  from  this  method  of  assist- 
ing nature  in  her  efforts  to  restore  an  abnormal  to  a  normal  condi- 
tion. Keefe  has  applied  suction  in  the  treatment  of  pyorrhea  alveo- 
laris with  good  results  by  taking  an  impression  in  wax,  removing  and 
cutting  the  wax  from  around  the  imprints  of  the  teeth,  thus  creating 
a  space  from  which,  after  reinserting  the  impression,  the  air  can  be 
withdrawn  by  means  of  a  large  bulb  or  syringe  attached  to  a  tube 
leading  through  the  impression  tray  and  into  the  space.  Other 
apparatuses  for  the  purpose  have  also  been  suggested. 

The  former  application  of  the  leech,  called  leeching,  was  some- 
what on  this  same  principle,  but  the  practice,  especially  in  dental 
therapeutics,  is  gradually  becoming  obsolete. 

SUGGESTION 

Suggestion,  as  used  in  therapeutics,  is  the  method  of  employing 
faith  or  confidence  in  the  treatment  of  disease.  There  is  no  doubt 
that  faith  is  one  of  the  oldest  therapeutic  agents  known.  Guerini^ 
refers  to  the  confidence  placed  in  ancient  times  in  the  power  of  the 
priests  to  cure  the  sick,  and  relates  how,  to  maintain  this  confidence, 
the  latter  gradually  resorted  to  the  administration  of  infusions  and 
decoctions  made  from  fresh  herbs,  etc.  With  all  peoples,  from  the 
earliest  centuries  to  the  present  day,  suggestion  has  ever  been  active. 
Where  the  disease  is  purely  functional,  and  not  organic,  the  influence 
which  the  mind  can  be  made  to  exert  over  the  body  is  a  potent  factor 

'Journal  of  the  American  Medical  Association. 
^  History  of  Dentistry. 


256  REMEDIES    OTHER    THAN    DRUGS 

in  the  treatment  of  the  condition,  whether  this  influence  be  called 
psychotherapy,  mental-healing,  Christian  Science,  or  by  some  other 
name. 

Hypnotism  is  practised  by  many  dentists  as  a  means  of  prevent- 
ing pain  and  controlling  patients.  Confidence  is  an  important  factor 
in  dental  practice.  The  dentist  should  ever  strive  to  win  the  con- 
fidence of  his  patients,  be  they  young  or  old,  and  when  obtained  he 
should  constantly  guard  against  abusing  it  by  careless  and  indifferent 
methods  of  operating. 


METROLOGY 

Metrology  is  the  science  that  treats  of  the  gravitating  force  of  a 
body,  called  weight;  its  extension,  bulk,  or  volume,  called  measure, 
and  the  relation  of  these  to  each  other,  called  specific  gravity. 

In  pharmacy,  liquids,  as  a  rule,  are  measured,  while  soHds  are 
weighed;  however,  certain  liquids  are  required  to  be  weighed.  The 
difference  between  measuring  and  weighing  some  liquids  is  not 
great,  while  with  others  it  is  considerable,  and  if  this  difference  is 
not  considered,  varying  results  frequently  follow.  This,  of  course, 
is  due  to  the  different  specific  gravity  of  the  liquids  {e.g.,  chloroform 
is  heavy  while  alcohol  is  light) . 

The  systems  of  weight  in  the  United  States  are  Avoirdupois  and 
Apothecaries',  or  Troy. 

The  United  States  Pharmacopeia,  in  all  of  its  editions  previous 
to  1880,  adopted  the  apothecaries'  weight  as  the  ofiQcial  standard. 
In  1880  the  parts-by-weight  system  was  adopted.  During  the  ten 
years  of  its  official  life  this  system  never  became  popular,  owing  to 
the  difficulty  of  having  to  weigh  all  liquids,  regardless  of  their 
specific  gravity.  However,  its  adoption  at  this  time  paved  the  way 
for  the  adoption  of  the  Metric  System  in  1890,  and  again  in  the  eighth 
and  ninth  decennial  revisions  of  the  U.S. P.,  in  1900  and  1910. 
The  metric  system,  therefore,  is  now  the  official  standard.  Never- 
theless, although  not  officially  sanctioned,  the  apothecaries'  weight 
still  remains  in  common  use  in  prescribing  medicines,  owiiig  to  the 
ease  with  which  it  can  be  subdivided  into  simple  fractions.  Through- 
out this  work  the  apothecaries'  weight  has  been  given  the  preference, 
the  metric  equivalent  being  enclosed  in  parentheses.  One  troy  ounce, 
equal  to  480  grains,  is  easily  divided  by  any  even  number — 2,  4, 
8,  etc.  This  quality  is  of  great  practical  value  to  the  dispenser 
and  prescriber  alike.  For  the  latter  it  simplifies  prescription-writing 
because  of  its  easy  division;  the  quantity  of  a  remedy  required  for 
administration  may  be  computed  with  the  measure  of  the  solvent 
very  quickly  in  simple  fractions. 

The  fluid  measure  used  in  pharmacy  can  always  be  reduced  to 
drams — the  equivalent  of  a  teaspoonful.  This  being  the  measure 
ordinarily  used  in  administering  medicines,  the  quantity  of  a  dose  is 

257 


258  METROLOGY 

readily  ascertained.  When,  for  example,  30  grains  of  potassium 
iodid  in  one  fluidounce  of  compound  syrup  of  sarsaparilla  is  pre- 
scribed, with  directions  "one  teaspoonful  at  a  dose,"  it  is  readily 
computed  that  the  quantity  of  potassium  iodid  in  each  dose  must  be 
3M  gr-7  since  one  fluidounce  contains  eight  fluidrams,  or  teaspoonfuls. 
The  tables  for  the  various  systems  of  weights  and  measures  are  here 
given : 

Troy,  or  Apothecaries'  "Weight 

20  grains  (gr.)  =  i  scruple  O)  =     20  grains. 

3  scruples  =  i  dram  (5)  =     60  grains. 

8  drams  =  i  ounce  ( § )  =     480  grains. 

12  ounces  =  i  pound  (lb.)  =5,760  grains. 

Wine,  or  Apothecaries'  Measure 

60  minims  (TTl)  =   i  fluidram  (f  5)- 

8  fluidrams  =   i  fluidounce         (f  o)- 

16  fluidounces  =    i  pint  (0). 

2  pints  =    I  quart  (qt.). 

4  quarts  =   i  gallon  (Cong.,  C.)  =  231  cubic  inches 

A  fluidounce  of  water  at  its  maximum  density  (4°C.)  weighs 
456.37  grains. 

Avoirdupois  Weight 

I  ounce  (av.  oz.)     =  437.5  grains. 

16  ounces  =  i  av.  lb. 

I  pound  =    7,000  grains. 

The  odd  number  of  grains  in  the  avoirdupois  ounce,  as  compared 
with  the  round,  easily  di\-ided  number  of  grains  of  the  apothecaries' 
ounce,  is  due  to  the  fact  that  in  the  latter  system  the  unit  is  the  ounce, 
and  from  this  the  pound  was  formed.  In  the  former  the  pound  is 
the  unit,  which  di\dded  by  16  gives  an  ounce  containing  only  437.5 
grains,  as  against  480  grains  in  the  apothecaries'  ounce. 

The  troy  or  apothecaries'  weight  is  used  in  the  compounding 
of  prescriptions;  the  wine  or  apothecaries'  measure  is  used  for  meas- 
uring liquids  in  pharmaceutic  work,  and  the  avoirdupois  weight  is 
in  common  use  generally.  The  troy  and  avoirdupois  pounds  are 
abbreviated  in  the  same  manner,  lb.,  but  differ  in  the  number  of 
grains  contained  (5,760,  7,000).  The  troy  pound  is  rarely  used, 
and  the  use  of  the  scruple  O)  is  practically  obsolete;  it  is  just  as 
convenient  to  write  for  20  grains,  and  there  is  less  Hkehhood  of  a  mis- 
take, for  the  abbreviation  for  scruple  may  be  taken  for  a  carelessly 
written  dram  mark. 


THE   METRIC    SYSTEM 

Approximate  Fluid  Measures 

Teaspoonful 

=  fSJ 

Dessertspoonful 

=  fSiJ 

Tablespoonful 

=  fSiv 

Wineglassful 

=  fBiJ 

Teacupful 

=  f§iv 

259 


One  cubic  inch  of  distilled  water,  at  its  maximum  density,  a  tem- 
perature of  4°C.  in  vacuo,  weighs  252.892  gr.,  and  231  cubic  inches  is 
a  measure  equivalent  to  the  U.  S.  gallon.  The  gallon  is  divided  into 
8  pints;  i  pint  into  16  fluidounces;  i  fluidounce  into  8  fluidrams, 
and  I  fluidram  into  60  minims.  The  measure  of  volume  may,  there- 
fore, always  be  compared  with  the  weight  of  water  as  above,  the 
standard  for  comparison,  thus: 

One  cubic  inch  =  252.892;  252.892  X  231  =  58,418  gr.  =  i    gallon. 
58,418  -T-      8  =     7,302  grains  =  i  pint. 

7,302  -T-    16  =  456.37  grains  =  i  fluidounce. 
456.37  -J-  480  =      0.95  grains  =  i  minim. 

For  all  practical  purposes  a  minim  may  be  considered  the  equiva- 
lent of  a  grain  (i  min.  =  0.95  gr.).  A  drop  is  not  a  minim,  although 
generally  considered  its  equivalent,  and  the  measurement  of  liquids 
by  drops  does  not  give  uniform  and  accurate  results.  The  size  of 
drops  varies  greatly  with  different  liquids ;  also  with  the  same  Hquids, 
according  to  the  conditions  governing  the  process  of  dropping. 
Among  these  conditions  may  be  mentioned: 

1.  The  quantity  of  the  liquid  contained  in  the  vessel. 

2.  The  size  and  shape  of  the  lip  of  the  vessel. 

3.  The  rapidity  of  the  dropping. 

4.  The  temperature  and  character  of  the  Hquid. 

THE  METRIC  SYSTEM 

The  metric  system  of  weights  and  measures  was  first  introduced 
in  France  at  the  close  of  the  eighteenth  century;  hence  it  is  often 
called  the  French  system.  Owing  to  its  decimal  parts,  it  is  frequently 
termed  also  the  decimal  system.  This  system  has  gradually  dis- 
placed all  the  various  systems  of  weights  and  measures  throughout 
the  European  continent,  and  is  the  only  recognized  system  in  all 
countries  except  Russia,  Great  Britain  and  her  colonies,  and  the 
United  States  of  America.  For  this  reason  the  metric  equivalent 
has  been  given  for  quantities  throughout  this  work. 


26o  METROLOGY 

Hallberg  states  that  because  of  its  simplicity  in  construction,  regularity  and 
convenience  in  exact  calculations,  it  has  become  the  only  system  for  scientific 
work,  and  is  no  doubt  destined  to  soon  displace  the  older  systems  in  art  and 
commerce  throughout  the  civilized  world.  Through  dur  system  of  decimal 
numbering — ones,  tens,  hundreds,  thousands,  etc. — the  monetary  systems  of  all 
civilized  nations,  except  Great  Britain,  have  also  become  decimal  and  brought 
with  them  the  metric  system. 

The  functions  of  money  and  weights  and  measures  are  so  intimately  related 
and  interdependent  that  a  decimal  system  in  one  practically  demands  a  decimal 
system  in  the  other.  The  decimal  system  of  money  was  one  of  the  privileges 
accorded  the  people  of  the  United  States  by  early  adoption,  but  while  adopting 
this  great  improvement  over  the  old  English  pound,  shilling,  and  pence,  the  old 
English  weights  and  measures,  based  on  the  penny-system,  were  unfortunately 
retained. 

Although  the  U.  S.  Government,  in  1867,  made  the  metric  system 
obligatory  in  the  three  branches  of  its  medical  service — the  Army, 
Navy,  and  Marine  Hospital — and  also  legally  permissible  through- 
out the  Union,  all  efforts  to  make  it  obligatory  in  the  various  States 
have  so  far  failed.  It  is  difl&cult  to  change  a  long-established  custom, 
but  it  does  seem  that  there  is  little  excuse  for  not  adopting  the  metric 
system  generally  in  the  United  States  with  our  decimal  proportions 
of  the  dollar,  the  dime,  and  the  cent,  based  upon  exactly  the  same 
principle. 

The  metric  system  is  based  upon  the  meter,  which  is  the  standard 
unit  of  linear  measure,  being  the  ten-millionth  part  of  one-fourth  of 
the  circumference  of  the  earth  (the  quadrant).  It  is,  therefore,  the 
one  forty-millionth  part  of  the  entire  circumference  of  the  earth 
taken  around  the  poles,  measured  by  a  ■  meridian  and  not  by  the 
equator. 

One  meter  is  equal  to  39.37  inches. 

The  liter  is  the  unit  of  liquid  measure,  and  is  the  cube  of  one-tenth 
of  the  meter,  or  cubic  decimeter,  and  one-thousandth  part  of  it,  or 
the  cube  of  one-hundredth  of  the  meter,  is  one  cubic  centimeter.  The 
term  "cubic  centimeter"  has  been  replaced  in  the  U.S.P.  IX  by  the 
word  "mil."  The  United  States  Bureau  of  Standards  declared  that 
the  term  cubic  centimeter  was  a  misnomer,  there  being  a  slight  dif- 
ference between  the  thousandth  part  of  a  liter  and  the  cubic  centi- 
meter, as  I  liter  was  determined  to  be  equivalent  to  1.000027 
cubic  decimeters.  The  Committee  of  Revision  decided  that  the 
time  had  come  to  adopt  the  word  mil,  the  first  three  letters  of  the 
whole  word  "milliliter."  In  this  work,  therefore,  the  abbreviation 
"mil"  is  used  instead  of  the  abbreviation  "c.c." 

The  unit  of  weight  is  the  gramme  or  gram,  the  weight  of  i  milli- 


EQUWALENTS    TO    THE    ENGLISH    WEIGHTS    AND    MEASURES       261 

liter  of  pure  water  in  vacuo  at  its  maximum  density,  and  is  equivalent 
to  15.432  grains. 

The  unit  gram  (written  mth  a  period  immediately  following, 
thus,  I.)  is  divided  or  multiplied  to  express  smaller  or  larger  denomi- 
national quantities,  respectively,  by  simply  mo\dng  the  decimal 
point  to  the  left  or  to  the  right.  This  illustrates  the  simplicity  of 
the  entire  system. 

To  designate  the  quantities  thus  obtained,  Latin  prefixes  are 
used  to  describe  those  less  than  one  gram,  and  Greek  those  larger 
than  one  gram — the  former  being  written  with  a  small  letter,  the 
latter  with  a  capital  letter. 


Metric  Weights 

I  myriagram 

(Mg.) 

=  10,000     grams. 

I  kilogram 

(Kg.) 

=    1,000     grams. 

I  hectogram 

(Hg.) 

=       100     grams. 

I  decagram 

(Dg.) 

=         10     grams. 

I  gram 

(Gm.) 

=  ■v\-eight  of  I  mil  of  water  at  4°C.  (unit) 

I  decigram 

(dg.) 

=          0.1       gram. 

I  centigram 

(eg.) 

=          o.oi     gram. 

I  milligram. 

(mg.) 

=          o.ooi  gram. 

Metric  Meastires  of  Capacity. 

I  myrialiter 

(Ml.) 

=  10,000,000  milliliters. 

I  kiloliter 

(Kl.) 

=     1,000,000  milliliters. 

I  hectoliter 

(HI.) 

=        100,000  milliliters. 

I-  decaliter 

(Dl.) 

=          10,000  milliliters. 

I  liter 

(L.) 

=            1,000  milliliters  (unit). 

I  deciliter 

(dl.) 

=              100  milliliters. 

I  centiliter 

(cl.) 

=                 10  milliliters. 

I  milliliter 

(ml.) 

=                   I  milliliter. 

Equivalents  to  the  English  Weights  and  Measures. ^ — Various 
methods  have  been  proposed  for  adapting  the  metric  weights  to  our 
apothecaries'  weights  used  in  prescription-writing  without  entaihng 
calculations  in  fractions,  as  the  exact  equivalent  would  necessarily 
do.  The  method  of  accepting  32  grams  as  equivalent  to  one  troy 
ounce  and  30  mils  as  equal  to  one  fluidounce  seems  to  be  the  least 
objectionable. 

To  convert  avoirdupois  or  troy  into  metric  weights,  the  equivalent 
of  the  gram  in  grains — 15.432 — should  be  remembered,  as  it  serves 
the  purpose  of  a  basis  for  obtaining  the  equivalent  of  all  the  higher 
denominations.  It  will  be  observed  that  this  number  is  composed 
of  the  first  five  numerals  in  reversed  order,  except  the  figure  i.     For 


262  METROLOGY 

all  practical  purposes  the  fraction  may  be  dropped,  and  i  Gm.  may 
be  said  to  equal  15  gr. 

The  Liter  is  equivalent  to  34fluidounces  (approximately  i  quart) ; 
half  a  Liter,  therefore,  approximates  i  pt.,  and  is  sometimes  called 
a  metric  pint  (17  fl.  oz.). 

The  Meter  is  equivalent  to  nearly  40  inches,  from  which  the 
divisions  may  easily  be  rendered  as  follows :  i  decimeter,  4  in. ;  i 
centimeter,  cm.,  0.4  in.;  i  millimeter,  mm.,  0.04  (3^5)  inch. 

Hallberg  sums  up  the  advantages  of  the  metric  system  as 
follows : 

1.  Simplicity  of  construction,  abolishing  complex  tables. 

2.  Uniformity,  through  its  adoption  in  all  scientific  work. 

3.  Permanency  and  stabiHty  of  its  standard  unit  derived  from 
the  earth  itself. 

4.  Facility  of  its  multiplication  and  division  by  decimal  points. 

5.  Commensurabihty  of  all  its  units  and  denominations  in 
weight,  volume,  linear  measures,  and  our  system  of  money. 

Eqiiivalents  of  Apothecaries'  in  Metric  Weights 


Grain. 

Gram. 

Grain. 

Gram. 

Moo     = 

.000324 

H 

= 

.0324 

H50     = 

.00043 

I 

= 

.0648 

Hoo     = 

. 00064 

2 

= 

.1296 

^5       = 

. 00086 

5 

= 

.3240 

Mo     = 

.00129 

8 

= 

.5184 

Mo    = 

.00162 

10 

= 

.6480 

Ho    = 

.00324 

15 

= 

.9720  (approx.  1.0  Gm.) 

Ho    = 

. 00648 

20 

= 

1 .  2960 

H     = 

.0108 

30 

= 

1 .  9440  (approx.  2.0  Gm.) 

K    = 

.0162 

40 

= 

2.5920 

H     = 

.0216 

60 

= 

3.888  (approx.  4.0  Gm.) 

Equivalents 

of  Apothecaries'  in 

Metric  Measures  of  Capacity  - 

Minims. 

Milliliters. 

Fluidounces.         Milliliters. 

I    = 

0.061 

I 

= 

29.57  (approx.  30.0  mils) 

2    = 

0.123 

2 

= 

59-14 

3     = 

0.185 

3 

= 

89.00 

5     = 

0.308 

4 

= 

118.29 

7     = 

0.431 

6 

= 

177.42 

10    = 

0.616 

10 

= 

295-73 

IS    = 

0 

.9: 

>4  (approx.  i.o  mil) 

12 

= 

355-00 

20    = 

I.  23 

16 

= 

473.17  (approx.  H  L.) 

30    = 

I 

.84  (approx.  2.0  mils) 

20 

= 

591-50 

40    = 

2.46 

24 

= 

710.00 

60    = 

3 

■7 

(approx.  4.0  mils) 

32 

= 

946.35  (approx.  I  L.) 

PERCENTAGE   IN    SOLUTIONS  263 

PERCENTAGE  IN  SOLUTIONS 

To  estimate  the  quantity  of  a  drug  required  to  make  a  certain 
volume  of  a  solution  of  a  given  percentage,  divide  the  weight  of 
the  volume  of  the  Hquid  to  be  used  as  the  solvent  by  loo,  and  multiply 
by  the  percentage.  Thus,  in  an  ounce  of  a  lo  per  cent,  aqueous 
solution  of  silver  nitrate  there  are  45.6  grains  of  the  salt. 

100  per  cent.  =  456.37  gr.  (weight  of  a  fl.  oz.  of  water). 
I  per  cent.  =  Koo  of  456-37,  or  4.56  gr. 
10  per  cent.  =  10  X  4.56,  or  45.6  gr. 

Therefore,  it  is  well  to  remember  that  4.56  gr.  or,  approximately, 
4.5  gr.  of  any  drug  added  to  a  fluidounce  of  water  makes  a  i  per  cent, 
solution  of  the  drug.  The  amount  of  a  drug  necessary  for  any  quan- 
tity of  any  per  cent,  solution  may  be  ascertained  by  rnuUiplying  the 
quantity  by  the  percentage,  and  the  product  by  4.5.  Thus,  to  ascer- 
tain the  amount  of  cocain  hydrochlorid  required  to  make  two  ounces 
of  a  1.5  per  cent,  solution,  we  would  multiply  2  X  1.5  X4.5  =  13.5  gr. 
Where  there  is  a  fraction  of  a  grain  in  the  ultimate  result  it  is  best 
to  drop  it  if  less  than  one-half,  or  raise  it  to  one  if  over  one-half. 

To  determine  the  weight  of  a  fluidounce  of  a  hquid  other  than 
water,  multiply  456.37  by  the  specific  gravity  of  the  liquid,  and  the 
product  will  be  the  weight  desired. 


PRESCRIPTION-WRITING 

The  literal  interpretation  of  the  word  prescription  is  a  written 
order  for  something — from  prcs,  for,  and  scribo,  1  write.  The  popular 
use  of  the  term,  however,  relates  to  medicines,  usually  meaning  a 
written  order  for  medicines,  although  it  is  frequently  employed  to 
designate  the  remedy  or  mixture  itself. 

The  art  of  prescription-writing  is  one  that  requires  practice  for 
its  perfection,  as  well  as  a  broad  knowledge  of  drugs,  their  actions 
and  their  doses,  and  their  indications  for  certain  diseases.  It  is 
also  essential  to  know  the  physical  and  chemic  properties  of  drugs 
as  related  to  the  form  of  administration  and  possible  combination 
with  other  substances.  Through  the  development  of  the  sciences  of 
pathology  and  pharmacology  we  have  learned  that  it  is  unnecessary 
to  exhaust  our  materia  medica  in  prescribing  for  any  one  disease, 
and  with  this  more  definite  knowledge  of  the  action  and  effects  of 
drugs  upon  the  diseased  tissues,  organs,  and  functions  of  the  body, 
we  find  that  only  a  few  agents  can  be  employed  with  actual  benefit 
in  our  endeavor  to  assist  Nature  in  her  efforts  to  restore  an  abnormal 
to  a  normal  condition.  To-day  simplicity  in  prescriptions  is  evi- 
dence of  a  broad  knowledge  of  the  conditions  to  be  met  by  the 
application  of  drugs  or  remedies  to  the  treatment  of  disease.  In 
former  days  many  drugs  were  combined  in  one  prescription,  and  the 
remedy  was  given  with  the  hope  and  expectancy  that  at  least  one 
ingredient  might,  perchance,  hit  the  spot.  To  such  formulas  the 
term  "shot-gun "  prescriptions  is  now  applied. 

The  most  important  considerations  in  writing  prescriptions  as 
well  as  in  reading  them  are: 

1.  The  language  and  abbreviations.  • 

2.  The  signs  and  terms. 

The  language  of  prescription-writing  is  primarily  Latin,  because 
pharmacopeial  titles  are  chiefly  used  in  designating  remedies. 
Medical  Latin  will  be  referred  to  later.  Abbreviations  in  prescrip- 
tion-writing are  perfectly  proper,  provided  they  are  not  carried  so 
far  as  to  cause  confusion  in  compounding  the  prescription.  The 
signs  and  terms  used  will  be  considered  conjointly  with  the  analysis 

of  a  prescription. 

264 


PRESCRIPTION-WRITING  265 

A  prescription  may  be  divided  into  five  parts,  as  follows: 

1.  The  superscription,  or  heading. 

2.  The  inscription,  or  names  and  quantities  of  ingredients. 

3.  The  subscription,  or  directions  to  the  compounder. 

4.  The  signa,  or  directions  to  the  patient. 

5.  The  name  of  the  prescriber,  his  degree,  and  the  date. 

The  superscription,  or  heading,  consists  of  the  abbreviation.!^, 
for  the  imperative  of  the  verb  recipio — recipe,  with  a  terminal  stroke 
on  the  R,  forming  the  sign  of  Jupiter,  x>  which  survives  as  a  relic 
of  ancient  times  when  all  medical  formulae  were  preceded  by  this 
sign  as  an  invocation  to  Jupiter,  the  chief  God.  Literally  translated 
"take  thou"  or  "take,"  it  tells  the  pharmacist  to  compound  the 
ingredients  which  follow.  The  name  of  the  patient  is  generally, 
though  not  necessarily,  included  in  this  part.  A  perfect  prescrip- 
tion should  always  bear  the  name  .of  the  person  for  whom  the  medicine 
is  intended,  and  if  for  a  child  it  should  be  so  designated. 

The  inscription,  containing  as  it  does  the  names  and  quantities 
of  the  ingredients,  is  the  most  important  part  of  the  prescription, 
and  the  ingredients  are  invariably  written  in  Latin  with  the  genitive 
ending,  the  quantities  following  on  each  line,  indicated  by  the 
customary  abbreviation.  Thus:  gr.  for  granum,  plural  grana — 
grain  or  grains;  5  for  dram  (drachma);  §  for  ounce  (unica);  and  O 
for  pint  (octarius).  The  abbreviations  lb.  for  pound  (libra)  and 
Cong,  or  C.  for  gallon  (congius)  are  rarely  employed.  TTl  stands  for 
minim  (minmum);  and  the  fluidrams  and  ounces  are  indicated  by 
the  prefex  fi,  thus  f5j,  f5j-  Semissis,  abbreviated  ss,  is  used  to 
indicate  a  half.  A  prescription  written  with  the  troy  system  of 
weights  always  contains  Roman  numerals:  gr.  iv,  gr.  xx,  etc.;  when 
written  with  the  metric  weights  and  measures  they  are  expressed 
in  decimals  in  Arabic  numerals,  followed  by  Gm.  or  mil,  signifying 
weight  or  measure:  5.65  Gm.,  30.0  mils. 

Signs  for  designating  the  measure  or  weight  of  the  mixture  are 
sometimes  affixed  to  the  last  ingredient.  The  most  commonly  used 
are: 

Ad,  the  preposition  "to;"  ad  f§iij  =  to  (measure)  three  fluid- 
ounces.  Quantum  sufficiat,  abbreviated  q.  s. — as  much  as  is  suffi- 
cient. Of  these  signs  q.  s.  is  preferable,  since  ad  may  be  confused 
with  the  abbreviation  of  the  verb  adde,  meaning  to  add.  Ana, 
abbreviated  da,  meaning  *'of  each,"  is  appended  when  the  same  quan- 
tities are  required  of  two  or  more  ingredients;  it  follows  the  last 
of  these,  just  preceding  the  quantity. 


266  PRESCRIPTION- WRITING 

While  it  is  the  rule  that  every  word  in  the  inscription  must 
terminate  in  the  genitive  or  accusative  (the  names  of  the  ingredients 
in  the  genitive,  the  quantities  in  the  accusative),  they  are  rarely 
written  out  in  full,  but  nearly  always  abbreviated.  Where  the  first, 
or  the  first  and  second,  syllables  of  words  are  the  same,  e.g.,  hydrar- 
gyrum and  hydrastis,  the  abbreviation  must  not  be  carried  so  far 
as  to  involve  doubt  as  to  which  drug  is  really  meant.  To  further 
illustrate,  the  drugs  just  mentioned  are  often  abbreviated  hydr., 
which  may  mean  either  of  them,  or  when  followed  with  chlor., 
would  doubtless  mean  hydrated  chloral,  but  might  also  be  mistaken 
for  hydrargyrum  chloridum;  both  calomel  and  mercuric  chlorid 
being  sometimes  erroneously,  though  not  infrequently,  so  written. 
The  author's  experience  behind  the  prescription-counter  leads  him 
to  emphasize  the  importance  of  correctly  writing  the  inscription. 

The  complete  inscription  is  made  up  of  the  basis,  or  active  con- 
stituent; the  adjuvant,  or  aid  to  the  basis;  the  corrective,  or  agent  to 
counteract,  modify,  or  correct  some  unpleasant  property  of  the 
basis ;  and  the  forming  substance.  The  forming  substance  is  variously 
termed  according  to  the  form  or  consistence  of  the  mixture.  For 
liquids  and  ointments  it  is  called  vehicle;  for  powders,  diluent;  and 
when  in  a  mass,  as  in  pills  or  troches,  excipient.  This  is  according 
to  the  maxim  of  Asklepiades,  which  reads  curare  (basis),  cito  (adju- 
vant), tuto  (corrective)  et  jucunde  (vehicle,  diluent,  or  excipient), 
to  cure  quickly,  safely,  and  pleasantly.  Most  prescriptions  do 
not  contain  all  of  these  ingredients;  many  call  for  but  one. 

The  subscription  consists  of  certain  signs  and  terms  conveying 
directions  as  to  the  compounding  and  dispensing.  Generally  it  is 
better  to  leave  the  detail  of  compounding  to  the  pharmacist  who  is 
trained  in  the  art  of  pharmacy;  therefore,  the  abbreviation,  M.,  which 
stands  for  the  Latin  imperative  of  the  verb  misce,  meaning  mix,  is 
usually  all  that  is  necessary.  This  sign  may  follow  a  dash,  thus 
— M.,  just  to  the  right  of  the  last  ingredient  in  the  inscription,  or 
it  may  be  placed  to  the  left  under  the  sign  of  the  superscription. 
When  special  directions  are  necessary,  as  in  directing  the  number  of 
powder,  capsules,  or  pills,  into  which  the  mixture  is  to  be  divided, 
they  may  be  written  in  either  Latin  or  EngHsh — the  former  is 
preferable,  provided  they  are  correctly  written. 

Special  directions  abbreviated  are: 

M.  ft.  pulv.  chart,  div.  No. — ,  mix  and  make  a  powder, 
divide  in  papers  No. — .  M.  ft.  cap.  No. — ,  mix  and  make 
capsules  No. — .  M.  ft.  mass.  pil.  div.  No. — ,  mix  and  make 
a  mass,  divide  in  pills  No.  — . 


PRESCRIPTION- WRITING  267 

The  Signa,  abbreviated  Sig.  or  S.,  includes  the  directions  to  be 
written  on  the  label  and  affixed  to  the  package  or  container.  These 
should  be  written  in  English  in  a  plain,  bold  hand-writing.  Some- 
times it  is  better  for  the  patient  not  to  know  what  drug  is  taken;  for 
this  reason  the  inscription  and  subscription  are  written  in  Latin,  but 
no  secrecy  is  necessary  here;  in  fact,  to  write  the  directions  in  plain 
EngKsh  and  to  read  them  to  the  patient  or  attendant  may  serve  as  a 
check  on  any  possible  error  in  copying  the  directions  on  the  label. 
The  stereotyped  expression,  "Use  as  directed,"  should  be  avoided 
as  far  as  possible,  especially  where  the  prescription  is  intended  for 
internal  administration.  Many  serious  consequences  might  have 
been  averted  if  specific  directions  had  been  given. 

The  name  of  the  subscriber,  his  degree,  and  the  date  are  added  be- 
.  low  the  signa.  Generally  it  is  not  in  good  taste  to  flourish  the  degree 
after  one's  signature  every  time  it  is  written;  but  in  the  case  of  a 
prescription  it  is  essential  for  authenticity.  The  pharmacist  desires 
to  know  whether  the  prescriber  has  the  right  to  prescribe,  and  this 
can  only  be  known  by  the  degree.  When  prescription  blanks  are 
used,  having  the  prescriber's  name,  degree,  and  address  printed 
above  or  below  the  space  reserved  for  the  prescription  proper,  all 
that  is  necessary  is  to  write  the  initials  and  the  date.  The  date  is 
valuable  for  reference. 

It  may  be  questioned  by  some  whether  dentists  have  the  right  to 
prescribe  internal  remedies.  A  large  part  of  the  work  of  the  dentist 
is  to  treat  the  diseases  of  the  mouth  and  adjacent  tissues,  thus  allevi- 
ating human  suffering,  and  surely  he  has  the  right  to  use  any  drug 
which  he  knows  from  his  experience  will  aid  Nature  in  overcoming 
the  pathologic  condition.  The  author  entered  upon  the  practice  of 
dentistry  through  the  gateway  of  pharmacy,  and  it  has  been  his 
experience,  both  as  a  pharmacist  and  as  a  dentist,  that  the  right  to 
prescribe  will  never  be  questioned  if  inteUigence  is  shown  in  the 
writing  of  the  prescription. 

The  order  usually  adopted  in  prescription- writing  is  as  follows: 
First,  after  the  I^,  the  names  of  the  ingredients  are  written,  in  the 
order  of  their  importance ;  then  the  number  of  doses  is  decided  upon ; 
the  individual  dose  of  each  drug  multiplied  by  the  number  of  doses 
■gives  the  quantities  to  be  afi&xed  to  the  names  of  the  ingredients. 
In  selecting  the  proper  quantity  for  Hquid  mixtures,  the  regular  sizes 
of  vials  alone  are  considered.  These  are  1,2,  and  4  dram,  and  i,  2,3, 
4,  6,  8,  and  16  ounce  capacity,  and  it  should  be  remembered  that  in 
all  cases  a  bottle  should  be  filled.  A  partially  filled  bottle  immedi- 
ately arouses  suspicion  on  the  part  of  the  patient  as  to  the  possi- 
bility of  mistake  in  compounding  the  prescription. 


MEDICAL  LATIN 

The  language  used  in  prescription-writing  is  primarily  Latin, 
because  pharmacopeial  titles  are  chiefly  employed  in  designating 
remedies.  It  is  never  necessary  to  tell  the  patient  what  drug  is  being 
used,  and  frequently  it  is  far  better  that  they  should  not  know,  because 
of  certain  idiosyncrasies,  prejudices,  and  other  reasons.  Therefore, 
it  is  wise  always  to  WTite  the  inscription  and  sometimes  the  sub- 
scription of  a  prescription  in  Latin.  The  rule  is  to  have  the  name  of 
every  ingredient  end  in  the  genitive  and  the  quantities  in  the  accusa- 
tive. It  is  true  that  much  ignorance  of  the  Latin  language  can  be 
covered  up  in  prescription- writing  by  using  abbreviations,  and  while 
it  is  also  true  that  to  abbreviate  is  perfectly  proper,  provided  it  is 
not  carried  so  far  as  to  involve  doubt  as  to  what  drug  is  wanted, 
nevertheless,  a  working  knowledge  at  least  of  this  dead  language  will 
be  of  inestimable  value.  Therefore,  a  few  rules  of  Latin  grammar 
applicable  to  prescription-writing  are  here  given:  The  quantities  of 
the  ingredients  appear  in  the  accusative  case,  governed  by  the  impera- 
tive of  the  verb  "Recipe;"  the  quantities,  however,  are  seldom  writ- 
ten out  in  full.  The  names  of  the  ingredients  appear  in  the  genitive 
case,  the  construction  reading  "Recipe  drachmam  unam  phenolis," 
take  one  dram  of  phenol,  I^  phenolis,  5j-  The  directions  to  the 
pharmacist  are  very  simple,  unless  special  instructions  are' necessary: 
M.  for  "misce,V  is  generally  all  that  is  required.  The  directions  to 
the  patient  should  always  be  written  in  EngHsh.  All  nouns  ending  in 
a  in  the  nominative,  end  in  ce  in  the  genitive,  and  are  of  the  first  de- 
clension; the  accusative  ends  in  am  and  the  nominative  plural  in  ce; 
there  are  a  few  exceptions  of  Greek  derivation,  such  as  enema,  gram- 
ma, theobroma — the  genitive  ending  for  these  is  atis.  Xouns  termi- 
nating in  us  in  the  nominative,  end  in  i  in  the  genitive,  and  are  of 
the  second  declension,  um  for  the  accusative  singular,  and  i  for  the 
nominative  plural;  there  are  a  few  exceptions  to  this  rule  with  nouns  of 
the  fourth  declension,  as  fructus  and  spiritus  (these  do  not  change  in 
the  genitive).  The  nouns  ending  in  um  in  the  nominative  singular 
are  neuter  in  gender  and  of  the  second  declension;  they  change  to  i 
in  the  genitive,  um  in  the  accusative,  and  a  in  the  nominative  plural. 

268 


MEDICAL    LATIN  269 

All  other  pharmacopeial  nouns  belong  to  the  third  declension  and 
change  variously  in  the  different  cases,  and  for  the  most  part  must  be 
studied  individually.  For  example:  as  becomes  atis;  is  may  remain 
is  or  change  to  idis,  itis,  or  eris  in  the  genitive;  the  accusative  of  as 
becomes  am,  the  nominative  plural  atea.  Some  nouns  do  not  change 
at  all,  e.g.,  sassafras.  Adjectives  agree  with  their  nouns  in  number, 
gender,  and  case;  those  ending  in  tis,  terminate  with  a  for  the  femi- 
nine and  um  in  the  neuter  gender,  and  are  declined  according  to  the 
first  and  second  declensions.  Adjectives  ending  in  is  and  ens  are 
decHned  according  to  the  third  declension;  the  first  ends  in  e  in  the 
neuter  gender.  A  few  nouns  of  Greek  origin  end  in  e,  and  form  a 
genitive  of  'is,  and  an  accusative  of  en;  aloe,  aloes,  is  an  example. 

When  special  directions  are  necessary  for  the  dispensing  of 
powders,  capsules,  and  pills,  they  may  be  given  as  follows:  Fiat  puhis 
et  divide  in  chartulas  No.  x. — make  a  powder  and  divide  into  lo 
papers.  Dispensa  in  capsulis  No.  xij — dispense  in  12  capsules. 
Fiant  pilulce  No.  xx — make  20  pills. 

An  official  formula  may  be  specified  in  a  prescription  as  follows : 
I^  Pulveris  opii  et  ipecacuanhse,  gr.  xx.  Fiat  chartulas  Xo.  iv. 
Sig.  — Take  one  or  two  powders  on  retiring  and  keep  well  covered. 
In  this  prescription  the  nominative  pulvi5  changes  to  pulver/5  in  the 
genitive;  opiww  changes  to  opw;  and  ipecacuanha  changes  to  ipeca- 
cuanha. Thus  the  value  of  the  above  rules  of  Latin  grammar  is 
seen.  To  abbreviate  the  names  of  the  ingredients  in  the  above,  we 
could  use  pulv.  for  pulveris,  ipecac,  for  ipecacuanhas,  but  we  could 
not  intelligently  abbreviate  opii — it  would  be  necessary  to  write  it  in 
full  in  the  Latin  nominative  or  the  English  (which  is  the  same  in  this 
instance — opium).  To  write  it  in  the  Latin  nominative  in  the  in- 
scription is  wrong,  and  to  write  it  in  EngHsh  with  the  other  words 
abbreviated  in  Latin  is  also  wrong.  So,  while  much  ignorance  of  the 
Latin  language  may  be  covered  up  by  abbre\-iation  in  prescription- 
writing,  occasionally  this  lack  of  knowledge  will  manifest  itself; 
therefore,  it  is  the  wiser  plan  to  become  familar  \\ith  these  simple 
rules.  As  has  been  elsewhere  stated,  the  art  of  prescription-writing 
is  one  that  requires  a  great  deal  of  practice  for  its  perfection. 

In  conclusion  the  author  desires  to  state  that  if  any  part  of  the 
inscription  or  subscription  cannot  be  properly  written  in  Latin,  by 
all  means  write  the  entire  prescription  in  Enghsh.  This  is  by  no 
means  meant  to  discourage  the  use  of  Latin  in  prescription-writing.^ 

Those  desiring  to  study  this  subject  further  will  find  St.  Clair's  "Medical  Latin" 
and  Robinson's  "Latin  Grammar  of  Pharmacy  and  Medicine"  excellent  books  for  the 
purpose. 


270  PRACTICAL   PRESCRIPTIONS 

EXAMPLES  OF  PRACTICAL  PRESCRIPTIONS 
Powders. 


For  Mrs.- 


I^ — Pulveris  Acetanilidi  Compositse,     gr.  xv  (i.o  Gm.) 
Fiat  chartulae  No.  ij. 
Sig. — Take  one  (i)  powder  at  once  and  the  other  in  two  (2) 
hours,  if  not  relieved. 
(Date)  ,  D.  D.  S. 

For  Baby . 


I^ — Hydrargyri  chloridi  mitis,  gr.  j  (0.06  Gm.) 

Sodii  bicarbonatis,                            gr,  xx  (1.3  Gm.) — M. 
Fiat  chartulae  No.  x. 
Sig. — Take  one  (i)  powder  every  hour  untU  three  (3)  or  four 
(4)  are  taken. 
(Date)  ,  D.  D.  S. 

For  Mr. . 


R — Acetphenetidini, 

SaJophen,  aa    gr.  x  (0.6  Gm.) 

Codeinse  Sulphatis,  gr.  j  (0.06  Gm.) — M. 

Fiat  chartulae  No.  iv. 
Sig. — Take  one  (i)  powder  every  three  (3)  hours. 

(Date)  — ,  D.  D.  S. 

Tooth  Powders. 

No.  I. 

For  General  Use. 
3 — Calcii  carbonatis  ppt.,  5xiv  (448.0  Gm.) 

Saponis  pulveris  (U.S. P.)    , 
Sacchari  pulveris,  aa     gij  (64.0  Gm.) 

Sodii  benzoatis,  Bss  (16.0  Gm.) 

Eucalyptolis,  lUx  (0.6  mil) 

Thymolis,  gr.  x  (0.6  Gm.) 

Cinnaldehydi,  lUxv  (i.o  mil)— M. 

Fiat  pulvis. 
Sig. — Use  as  a  general  tooth  powder. 

(Date)  ,  D.  D.  S. 

No.  2. 

For  General  Use. 

'^, — Calcii  carbonatis  ppt.,  Bxx  (640.0  Gm.) 

Orris  radices  pul v.,  giv  (128.0  Gm.) 

Saponis  pulv.  (U.S.P.),  gij  (64.0  Gm.) 
Sacchari, 

Sodii  boratis,  aa         5j  (32.0  Gm.) 

Thymolis,  gr.  xv  (1.0  Gm.) 


PRACTICAL   PRESCRIPTIONS  271 

Eucalyp  tolis,  TTlx  (0.6  mil) 

Olei  gaultherias, 

Olei  menthae  piperitae,  aa    lUxx  (1.3  mils) — M. 

Fiat  Pulvis. 
Sig. — Use  as  a  general  tooth  powder. 

(Date)  ,  D.  D.  S. 

Capsules. 

For  Mr. . 


I^ — Quininae  bisulphatis,  gr.  xxiv  (1.5  Gm.) 

Dispensa  in  capsulis  No.  viij. 
Sig. — Take  one  (i)  capsule  before  meals  and  on  retiring 

(Date)  — ,  D.  D.  S. 


PiUs, 


For  Mrs. 


I^ — Quininae  valerianatis,  gr.  xviij  (1.2  Gm.) 

Extracti  hyoscyami,  gr.  iv  (0.26  Gm.) 

Extracti  cinchonae,  gr.  viij  (0.5  Gm.) — M. 

Fiat  massa  et  divide  in  pilulae  No.  xij. 
Sig. — Take  one  (i)  pill  before  meals  and  on  retiring 

(Date)  ,  D.  D.  S. 


{Cosmos.) 


Solutions  (Dobell's  Solution). 
For  Mr. . 


I^ — Sodii  bicarbonatis, 

Sodii  boratis,  aa     3j  (4-o  Gm.) 

Phenolis  (crys.),  3ss  (2.0  Gm.) 

Glycerini,  f§j  (30.0  mils) 

Aquae,  Oij  (i.o  L.)— M 
Sig. — Use  as  a  spray,  mouth-wash,  or  gargle. 

(Date)^  ,  D.  D.  S. 

(Antiseptic  Solution  N.F.) 

For  Mrs. . 

I^ — ^Liquoris  Antiseptici,                         f§viij  (240.0  mils) 
Sig. — Dilute  with  one-half  warm  water  and  use  as  a  mouth-wash. 
(Date)  ,  D.  D.  S. 

For  Miss . 


I^ — Antipyrini,  5ss  (2.0  Gm.) 

Sodii  bromidi,  5j  (4-o  Gm.) 

Glycerini,  f3ij  (8.0  mils) 

Aquae  cinnamomi,         q.  s.  ad.      fgj  (30.0  mils) — M. 
Sig. — Take  a  teaspoonful  three  times  a  day,  after  meals. 

(Date)  ,  D.  D.  S 


272                                           PRACTICAL    PRESCRIPTIONS 
For  Mrs, • 


I^ — Potassii  iodidi,  5J5S  (6.0  Gm.). 

S>Tupi  sarsaparillae  comp.,               f^iij  (90.0  mils) — M. 
Sig.^Take  a  teaspoonful  in  water  three  times'  a  day,  after  meals. 
(Date)  ,  D.  D.  S. 

For  Mr. . 


I^ — Acetailnidi,  gr.  viij  (0.5  Gm.) 

Syrupi  simplex,  fSss  (15.0  mils) 

Spiritus  frumenti,  q.  s.  ad.     f  oiij  (90.0  mils) — M. 
Sig. — Take  one-half  at  once  and  the  remainder  in  two  (2)  hours, 
if  not  relieved. 

(Date)  '■ ,  D.  D.  S. 

Collyrium  (Eye-water). 

For  Mr. . 


I^ — Sodii  boratis,  gr.  x  (0.6  Gm.) 

Acidi  borici,  sat.  sol.,                       f5j  (30-°  mils) — ^SI. 
SigT — Warm  to  body  temperature  and  drop  into  the  eye  with  a 
drop  applicator. 
(Date)  ,  D.  D.  S. 

Gargle  (Mercurial  Stomatitis  or  Sore  Throat). 

For  Miss . 

I^ — Potassii  chloratis,                              5jss  (6.0  Gm.) 
Tincturae  mj-rrhae,                            f5'j  (8.0  mils) 
Alcoholis,                                           fgss  (15.0  mils) 
Aquae  cinnamomi,                              fSvi  (180.0  mils) — M. 
Sig. — Thoroughly  gargle  the  throat  three  times  daily.     If  too 
strong,  dilute  with  warm  water. 
(Date)  .  D.  D.  S. 

Liniments. 

For  Dentists^  Use. 
I^ — Mentholis, 

lodi  (crys.)  aa     gr.  x  (0.6  Gm.) 

Chloroformi,  f  Sj^s  (6.0  mils) 

Tincturae  Aconiti,  q.  s.  ad.  fsj  (30.0  mils) — M. 
Sig. — Use  as  a  refrigerant  counterirritant. 

(Date)  ,  D.  D.  S. 

For  Dentists'  Use. 
I^ — Mentholis,                                           gr.  xx  (1.3  Gm.) 
Chloroformi,                                       fSJss  (6.0  rrdls) 
Tincturae  aconiti,               q.  s.  ad.  foj  (30.0  mils) — M. 
Sig. — Apply  freely  to  gums  in  cases  of  nonseptic  pericementitis. 
(Date)  .  D.  D.  S. 


PRACTICAL    PRESCRIPTIONS  273 


For  Mr. 


I^— Camphorae  (gum),  3ij  (8.0  Gm.) 

Tincturae  aconiti,  fgj  (30.0  mils) 

Linimenti  saponis,  q.  s.  ad.  fgiij  (90.0  mils)— M. 

Sig. — Apply  locally  with  massage  in  case  of  neuralgia. 

(Date)  ,  D.  D.  S. 


INCOMPATIBILITY  IN  PRESCRIPTIONS 

When  two  or  more  different  substances  are  brought  together  in 
a  mixture,  be  it  liquid  or  soHd,  with  the  result  of  undergoing  a  more 
or  less  complete  change,  not  intended,  they  are  said  to  he  incompatible. 

Incompatibility,  so  far  as  it  applies  to  the  combination  (not  the 
action)  of  drugs,  may  be  of  two  kinds — physical  and  chemic.  The 
only  truly  scientific  method  of  determining  the  incompatibility,  or 
the  contrary,  of  the  ingredients  of  a  mixture  is  a  correct  knowledge 
of  physical  and  chemic  laws  and  their  practical  application  iii 
pharmacy  and  therapeutics. 

Physical  incompatibility  is  largely  a  question  of  the  solubility  of 
drugs.  It  results  when  precipitates  are  formed  without  the  precipi- 
tated substance  losing  its  former  identity;  i.e.,  without  chemic 
change.  It  also  occurs  when  an  effort  is  made  to  mix  nonmiscible 
substances,  as  oil  and  water. 

Gums  and  other  mucilaginous  substances  are  soluble  in  water, 
but  insoluble  in  alcohol.  Therefore,  the  addition  of  alcohol  to  an 
aqueous  solution  of  a  gum  results  in  the  precipitation  of  the  gum 
without  chemic  change. 

Example:  Mucilage  of  tragacanth  with  any  alcohoHc  tincture 
(tincture  of  aconite)  will  precipitate  the  tragacanth. 

Resinous  substances  are  soluble  in  alcohol,  but  insoluble  in  water. 
The  addition  of  water,  therefore,  to  an  alcoholic  solution  of  a  resin 
results  in  the  physical  precipitation  of  the  resin. 

Example:  Water  added  to  tincture  of  podophyllum  will  precipitate 
the  resinous  active  constituent,  podophyllin. 

Any  mouth-wash  or  solution  containing  a  considerable  amount  of 
the  essential  oils,  held  in  solution  by  alcohol,  will  become  turbid  upon 
the  addition  of  water,  owing  to  the  physical  incompatibiHty  of  the 
oil  and  water.    ' 

Chemic  incompatibility  involves  a  chemic  change  when  sub- 
stances are  mixed,  whereby  their  former  identity  is  lost.  To  be 
able  to  predict  chemic  incompatibiHty  requires  a  knowledge  of 
chemic  laws  and  their  practical  appUcation.  It  is  well  to  remember 
a  few  of  the  more  common  of  these  laws.     For  example: 

I.  It  is  a  principle  in  chemistry  that  when  solutions  of  soluble 
salts  are  brought  together  there  is  generally  an  exchange  of  radicals 

274 


INCOMPATIBILITY   IN   PRESCRIPTIONS  275 

with  the  formation  of  a  precipitate,  if  either  of  the  newly  formed  salts 
is  insoluble.  To  illustrate:  When  solutions  of  silver  nitrate  and 
sodium  chlorid  are  brought  together  a  white  precipitate  of  silver 
chlorid  is  formed.  Here  there  is  an  exchange  of  radicals,  and  the 
silver  chlorid,  being  insoluble  in  the  water,  is  precipitated,  while 
the  sodium  nitrate,  being  soluble,  dissolves  as  soon  as  it  is  formed. 
Advantage  is  taken  of  chemic  incompatibility  when  silver  nitrate  is 
used  about  the  mouth;  any  excess  can  be  neutralized  at  once  by 
having  the  patient  rinse  the  mouth  with  a  solution  of  common  salt. 

2.  Strong  mineral  acids  decompose  salts  of  the  weaker  mineral 
or  vegetable  acids,  and  also  form  ethers  with  alcoholic  preparations. 
To  illustrate:  Sodium  bicarbonate  is  chemically  incompatible  with 
hydrochloric  acid.  Here  the  chlorin  of  the  hydrochloric  acid  has 
a  greater  affinity  for  sodium  than  has  the  weaker  carbonic  radical, 
hence  it  displaces  the  latter,  forming  sodium  chlorid  and  liberating 
carbonic  acid,  which  immediately  breaks  up  into  water  and  carbon 
dioxid.  The  carbon  dioxid,  being  a  gas,  causes  the  effervescence. 
An  illustration  of  the  formation  of  ethers  by  adding  a  strong  mineral 
acid  to  alcohoUc  solutions  is  found  in  making  ether,  where  sulphuric 
acid  is  added  to  alcohol.  In  this  case,  of  course,  sulphuric  acid  and 
alcohol  are  not  considered  incompatible  because  ether  is  the  product 
desired ;  but  if  it  were  not,  then  they  would  be  chemically  incompatible. 

As  a  matter  of  fact,  all  drugs  are  incompatible  with  their  chemic 
tests  or  antidotes,  a  knowledge  of  which  means  a  knowledge  of  the 
science  of  chemistry,  and  to  mention  all  would  be  inappropriate 
in  a  work  of  this  kind.     A  few  common  examples  are  here  given: 

Alkalies  and  alkaline  carbonates  are  incompatible  with  acid  solu- 
tions, acid  salts,  and  alkaloidal  salts.  Arsenic  trioxid  with  tannic 
acid  and  salts  of  iron.  Alkaloids  and  alkaloidal  salts  with  tannic 
acid.  Phenol  with  collodion.  Powerful  oxidizing  agents  with  easily 
cxidizaUe  substances,  causing  combustion,  and  even  explosion.  Oxid- 
izing agents  are:  potassium  chlorate,  potassium  permanganate, 
chromic,  nitric,  and  nitrohydrochloric  acids.  Easily  oxidizable 
agents  are:  sugar,  glycerin,  alcohol,  fats,  sulphur,  carbon,  and 
phosphorus. 

The  following  drugs,  so  far  as  possible,  had  better  be  prescribed 
alone : 

Strong  mineral  acids.  Potassium  Chlorate. 

Alkalies.  Potassium  Permanganate. 

Arsenic  Trioxid.  Silver  Nitrate. 

Iron  salts.  Tannic  Acid. 

Mercuric  Chlorid  (incompatible  with  almost  everything). 


276  ANTAGONISM   OF   DRUGS 

ANTAGONISM  OF  DRUGS 

As  has  been  observed  in  the  study  of  physiologic  action,  certain 
drugs  produce  opposite  effects.  This  is  known  as  antagonism  of 
drugs,  called  also  physiologic  or  therapeutic  incompatibility.  The 
antagonistic  effects  of  drugs  are  recognized  in  therapeutics  as  a  means 
of  guarding  against  drug  poisoning  and  as  an  aid  in  the  treatment  oj 
poisoning  when  toxic  symptoms  are  manifested.  In  this  connection 
the  term  physiologic  antidote  is  used. 

The  antagonistic  action  of  drugs,  however,  is  never  as  positive 
as  is  the  case  with  chemic  incompatibility,  for  there  are  few  drugs, 
indeed,  whose  action  is  directly  opposite,  and  whose  effects  will 
neutralize  completely  the  effects  of  other  drugs.  The  antagonism 
of  drugs  or  physiologic  antidotes  is  well  illustrated  in  the  treatment 
of  cocain  poisoning  {see  p.  1^2). 


DENTAL  STERILIZATION 

GENERAL  CONSIDERATIONS 

Throughout  Part  II  of  this  work  on  Practical  Dental  Therapeu- 
tics the  author  will  endeavor  to  emphasize  the  importance  of  dental 
sterilization. 

The  term  Sterilization  as  used  in  medical  and  dental  practice, 
means  a  process  by  which  the  destruction  or  removal  of  aU  micro- 
scopic living  organisms  and  their  spores  is  accomplished.  Some 
bacteria,  under  certain  conditions,  undergo  a  transformation  into  a 
resting  stage  when  they  are  called  spores.  In  the  spore  state  they 
are  able  to  resist  influences  which  would  kiU  the  bacteria.  Most 
disease-producing  germs  do  not  form  spores  and,  therefore,  are 
easily  killed.  The  anthrax  and  tetanus  bacilli  are  exceptions  to 
this,  as  their  spores  are  quite  resistant.  An  object  which  is  free  from 
living  microorganisms  is  spoken  of  as  being  "sterile,"  but  it  should 
be  remembered  that  this  condition  can  be  maintained  only  so  long 
as  the  necessary  precautions  are  taken  to  prevent  contact  with  the 
atmosphere  or  other  media  or  instrument  which  may  carry  micro- 
organisms. 

The  methods  and  means  of  sterilizing  tooth-structure  and  the 
field  of  operation  will  be  fully  discussed  in  the  description  of  the 
various  operations  which  are  performed  in  and  about  the  mouth;  and 
while  the  importance  of  having  the  instruments  and  material  used, 
as  well  as  the  operator's  hands,  in  a  sterile  condition  will  be  repeat- 
edly mentioned,  in  all  operations  which  involve  in  any  way  the  soft 
tissues  of  the  mouth  where  an  infection  may  follow,  the  means  of 
sterilizing  the  same  should  now  be  discussed.  The  importance  of 
personal  cleanliness  on  the  part  of  the  dentist  and  of  his  armamen- 
tarium is,  of  course,  understood  and  need  not  be  considered  here. 

A  principle  in  modern  surgery  is  to  prevent  the  presence  of  germs. 
This  means  that  the  instruments  and  materials  used  must  be  sterile, 
as  well  as  the  field  of  operation  and  the  operator's  hands.  The  same 
principle  holds  true  in  dental  as  well  as  general  surgery. 

METHODS  OF  DENTAL  STERILIZATION 

Direct  Flame. — In  dental  practice  it  is  often  possible  to  sterilize 
small  objects  by  the  direct  application  of  heat  from  the  flame  of 

277 


278  DENTAL   STERILIZATION 

the  Bunsen  burner  or  lamp,  provided  the  object  will  not  be  injured. 
Such  instruments  as  burnishers,  root-canal  pluggers,  platinum  needles, 
the  points  of  pliers  used  for  handling  steriUzed  cotton,  gutta-percha 
points,  etc.,  may  be  rapidly  steriHzed  in  this  manner  by  holding 
them  in  the  flame,  or  playing  the  latter  over  them  a  few  times. 

Moist  Heat. — The  use  of  live  steam  for  sterilization,  usually  in  a 
covered  kettle  or  boiler,  electrically  or  otherwise  heated,  is  gererally 
applicable  for  sterilizing  dental  instruments,  such  as  broaches,  burs, 
pyorrhea  scalers,  etc.  There  are  many  practical  devices  on  the 
market  for  this  purpose.  By  practical  here  we  take  into  considera- 
tion the  convenience  and  expense.  Such  an  apparatus  must  be 
convenient  to  use,  and  no  reasonable  amount  of  expense  should 
deter  dentists  from  accompUshing  this  end.  Live  steam  has  great 
penetrating  power,  and  a  temperature  of  ioo°C.  (the  boiling  point 
of  water)  for  from  three  to  five  minutes  generally  is  sufficient  for  the 
sterilization  of  such  dental  instruments  as  may  be  thus  sterilized, 
and  which  are  used  and  so  sterilized  several  times  daily.  The  instru- 
ments should  be  brushed  with  a  stiff  brush  to  remove  whatever  de- 
bris may  be  present  before  they  are  placed  in  the  steriUzer,  and  the 
latter  should  be  rinsed  and  fresh  water  added  every  morning.  In 
cases  of  questionable  specific  infection,  the  instruments  should  be 
boiled  for  at  least  fifteen  minutes.  Sodium  carbonate  or  borax 
should  be  added  to  the  water  to  prevent  tarnishing  and  probable 
rusting  of  the  instruments. 

Dry  Heat. — This  method  requires  the  object  to  be  heated  in  an 
oven  or  suitable  apparatus  at  a  temperature  of  from  160°  to  lyo^C, 
continued  for  at  least  two  hours.  Up  to  the  present,  apparatus 
for  the  practical  sterilization  of  the  material  used  in  dental  surgery, 
such  as  cotton,  gauze,  etc.,  have  not  been  obtainable;  and,  therefore, 
dentists  have  reHed  largely  upon  obtaining  this  material  in  sterile 
condition  from  the  manufacturers.  Even  if  this  be  possible,  which 
is  open  to  question,  the  material,  with  the  best  of  ordinary  care,  be- 
comes contaminated  in  the  office.  It  is  important,  therefore,  that 
all  such  material  as  may  be  sterilized  by  dry  heat  should  be  so 
sterilized  just  previous  to  use;  and  the  better  way  to  be  assured  of 
sterilization  is  to  prepare  this  material  in  advance  and  keep  it  in  a 
dry  heat  sterilizer  ready  for  use.  Such  sterihzers  are  now  on  the 
market,  and  improved  ones  are  being  constructed.  They  should  be 
a  part  of  the  equipment  of  every  practising  dentist.  Where  the 
material  is  kept  constantly  ready  for  use  in  such  sterilizers,  a  much 
lower  heat  than  160°  to  i7o°C.  is  sufficient. 

Chemic  Agents. — For  the  purpose  of  assisting  in  sterilization  or 


DENTAL   STERILIZATION  279 

of  protecting  substances  from  subsequent  contamination,  chemic 
agents  are  frequently  employed.  It  is  to  be  regretted  that  many  of 
our  most  potent  disinfectants,  such  as  formaldehyd,  mercuric  chlorid, 
etc.,  while  excellent  for  the  sterilization  of  the  hands  and  the  site  of 
operation,  cannot  be  used  for  the  sterilization  of  metal  instruments, 
on  account  of  the  agents  acting  deleteriously  upon  the  metal.  These 
agents,  therefore,  should  be  used  only  as  adjuncts,  and  generally  in 
quantities  insufficient  to  insure  sterility  in  themselves. 

This  method  is  used  in  dentistry  for  the  following  purposes: 

1.  For  the  disinfection  of  the  hands  and  the  site  of  operation. 

2.  For  the  disinfection  of  tooth-structure,  such  as  carious  dentin, 
gangrenous  canals,  etc.  Here  stronger  solutions  of  the  drug  may  be 
safely  employed — thus  approaching  more  nearly  complete  steriHza- 
tion  than  should  be  expected  from  the  general  use  of  chemic  agents 
for  this  purpose. 

3.  For  the  disinfection  of  glass  containers,  etc.,  alcohol  being 
chiefly  used  for  the  purpose;  but  sterilization  by  heat  is  better. 

4.  To  maintain  in  a  sterile  condition  various  remedies,  such  as 
local  anesthetic  solutions,  antitoxins,  serums,  vaccines,  etc. 

If  done  with  aseptic  precautions,  it  is  best  for  the  dentist  to 
prepare  local  anesthetic  solutions  at  the  time  they  are  intended  to 
be  used.  However,  stock  solutions  may  be  safely  employed  and  can 
be  kept  sterile  indefinitely  by  the  addition  of  0.5  per  cent,  of  phenol 
or  0.4  per  cent,  of  cresol.  The  latter  is  from  two  and  a  half  to  three 
times  as  strong  a  disinfectant  as  phenol  and  scarcely  more  poisonous. 

It  is  impossible  to  set  definite  Umits  which  will  fit  all  cases  for 
the  amounts  of  the  chemicals  which  may  be  employed,  because  the 
composition  of  the  substance  and  its  degree  of  contamination  are 
important  factors  in  steriHzation. 

Gutta-percha  points  may  be  positively  sterilized  by  immersion 
in  a  10  per  cent,  solution  of  formaldehyd  or  in  a  70  per  cent,  solu- 
tion of  alcohol,  to  which  latter  solution  should  be  added  one  grain 
of  thymol  to  the  fluid  ounce.  This  solution  will  be  known  through- 
out the  text  here  as  modified  alcohol.  It  is  an  excellent  solution  for 
the  chemic  steriUzation  of  the  teeth  included  in  the  rubber  dam,  and 
for  the  immediate  sterilization  of  carious  dentin.  It  may  not  com- 
pletely steriHze  in  the  latter  instance,  but  it  aids  greatly  in  estab- 
lishing asepsis.  Of  the  organic  bodies,  alcohol  stands  first  in  dental 
practice  as  a  disinfectant.  It  is  an  efficient  antiseptic  when  present 
by  volume  in  from  20  to  40  per  cent.  Solutions  containing  from 
40  to  70  per  cent,  are  actively  disinfectant,  the  latter  strength  being 
most  effectual.     Above  70  per  cent,  its  efficiency  tends  to  diminish. 


28o  DENTAL    STEEILIZATION 

lodin  is  one  of  the  most  effective  disinfectants,  and  preparations 
containing  free  iodin  in  material  proportions  become  sterile  of  them- 
selves. For  this  reason  solutions  of  iodin  are  valuable  and  largely 
used  for  sterilizing  the  mucous  membrane  previous  to  making  sub- 
mucous injections  of  local  anesthetics,  and  before  operating  upon 
the  part. 

The  responsibility  of  having  all  instruments  and  material  used 
in  dental  surgery  sterile,  where  it  is  possible  to  cause  an  infecHon 
through  an  open  wound  or  otherwise,  is  rightfully  thrown  upon  the 
dentist;  and  in  assuming  this  responsibility  he  should  study  carefully 
the  various  methods  of  sterilization,  and  exercise  judgment  in  his 
application  of  the  principles  involved. 


PART  II 

PRACTICAL  DENTAL  THERAPEUTICS 
GENERAL  CONSIDERATIONS 

Therapeutics  is  the  application  of  drugs  or  remedies  to  the  treat- 
ment of  disease.  Dental  therapeutics  differs  in  no  way  from  general 
therapeutics,  except  that  it  includes  only  the  treatment  of  diseases  of 
the  mouth  and  adjacent  structures  or  such  general  diseases  as  are 
manifested  in  the  mouth.  In  the  latter  instance  it  is  the  duty  of  the 
dentist  to  collaborate  with  the  family  physician  in  the  treatment 
of  the  case.  In  this  day  when  so  many  systemic  diseases  are  known 
to  be  directly  traceable  to  foci  of  infection  in  the  mouth,  it  is  more 
essential  than  ever  that  the  physician  and  dentist  work  together  in 
harmony  for  the  relief  of  suffering  humanity. 

In  considering  the  practical  therapeutics  of  the  more  common 
diseases  which  the  dentist  is  called  upon  to  treat,  the  author  will 
draw  largely  upon  his  own  experience  gained  from  actual  practice 
and  irom  extenisive  reading  of  current  dental  and  medical  literature. 

It  should  be  understood  at  the  outset  that  there  are  three  essen- 
tial factors  upon  which  all  successful  therapeutics  rests.  First,  to  be 
able  to  recognize  a  pathologic  condition  and  make  a  correct  diag- 
nosis. This  means  that  the  successful  therapeutist  must  possess 
a  broad  knowledge  of  general  pathology  and  a  special  knowledge  of 
dental  or  oral  pathology;  secondly,  to  know  what  drug,  or  remedy, 
if  properly  applied  or  administered,  will  reach  the  recognized  patho- 
logic condition  and  act  the  most  favorably.  This  means  that  suc- 
cessful therapy  depends  upon  a  broad  knowledge  of  pharmacology 
— a  science  which  treats  of  the  action  of  drugs  and  remedies  upon 
the  tissues,  organs,  and  functions  of  the  body;  and  thirdly,  to  have 
at  hand,  in  a  convenient  and  practical  form,  that  drug  or  remedy 
which  experience  has  taught  will  assist  Nature  in  her  efforts  to  restore 
an  abnormal  to  a  normal  condition. 

The  tendency  in  dental  as  well  as  in  general  therapeutics  to-day 
is  to  place  the  treatment  of  disease  upon  a  rational  basis.  The  pro- 
gressive dentist,  therefore,  is  no  longer  satisfied  to  know  that  results 
may  be  obtained  by  the  use  of  certain  remedies  in  the  treatment  of 
certain  diseases,  but  he  has  a  strong  desire  to  know  also  why  those 


252  PRACTICAL   DENTAL   THEEAPEUTICS 

results  are  brought  about.  In  the  following  pages  only  such  patho- 
logic data  will  be  given  as  are  deemed  essential  to  the  therapeutics 
of  the  condition  under  consideration,  but  every  effort  will  be 
made  to  tell,  as  far  as  is  known,  why  the  reinedies  suggested  are 
indicated  and  what  may  be  expected  from  their  judicious  employ- 
ment. This  means  that  it  will  be  necessary  to  practically  discard 
all  obsolete  or  untried  remedies.  In  other  words,  only  such  remedies 
will  be  considered  in  detail  here  as  have  been  found  to  be  of  real 
practical  value. 


DISEASES  OF  THE  HARD  TISSUES  OF  THE  MOUTH  AND 
ASSOCIATED  STRUCTURES 

HYPERSENSITIVE  DENTIN 
GENERAL  CONSIDERATIONS 

In  the  early  history  of  civilization,  we  find  that  the  possession 
of  the  cardinal  virtue  of  fortitude  was  considered  a  mark  of  courage, 
strength  and  character,  because  it  enabled  the  individual  to  willingly 
undergo  the  necessary  pain,  peril  or  danger  incident  to  Hfe.  But 
the  discovery  of  anesthesia  by  humanity's  greatest  benefactor, 
Horace  Wells,  the  dentist,  together  with  the  humanitarian  tendencies 
of  the  years,  have  so  changed  human  nature  that  we  find  few  people 
to-day  who  possess  in  any  marked  degree  the  spirit  of  fortitude 
as  manifested  in  ancient  times.  Among  other  things  in  life,  this 
condition  of  affairs  demands  more  painless  methods  of 'practising 
dentistry.  The  one  -dental  operation  which  has  caused  more  pain 
in  the  past  than  all  others  combined  is  that  of  the  preparation  of 
cavities  in  vital  teeth. 

Ever  since  the  art  of  filling  teeth  was  first  begun  both  the  dentist 
and  patient  have  cherished  the  ardent  hope  that  some  day  it  would 
be  possible  to  perform  this  operation  without  pain.  Especially  is 
this  true  in  these  modern  times  when,  to  carry  out  the  basic  principles 
of  cavity  preparation,  as  understood  to-day,  it  is  necessary  that  the 
cavity  have  a  flat  seat  with  practically  parallel  walls;  that  it  should 
possess  powers  of  resistance  and  retention,  and  be  of  convenient  form, 
and  that  the  outHne  be  carried  to  areas  of  immunity — all  of  which 
requires  drilling  into  sound  and  usually  extremely  sensitive  dentin. 

Authorities  differ  in  regard  to  the  sensitivity  of  dentin.  Accord- 
ing to  Barrett,  dentin  in  the  normal  condition  should  be  without 
sensation ;  the  source  of  sensitive  dentin,  or  of  impressionable  pulps, 
lies  in  their  continued  subjection  to  irritation  by  which  responsive- 
ness is  developed.  Burchard-IngHs  states  that  all  vital  dentin  is 
sensitive;  that  the  degree  of  sensitivity  differs  markedly  in  indi- 
viduals; and  it  is  only  when  hypersensitiveness  is  observed  that  the 
condition  becomes  pathologic.  It  might  also  be  mentioned  that 
the  sensitivity  differs  in  the  same  individual  at  different  times. 
Black  differentiates  between  hypersensitiveness  and  thermal  sensi- 
tiveness of  dentin,  claiming  that  the  sharp  pain  caused  by  sudden 

283 


284  PRACTICAL   DENTAL   THERAPEUTICS 

changes  of  temperature  is  normal,  though  no  other  tissue  or  organ 
of  the  body  shows  a  like  resistance  to  thermal  changes.  Under 
certain  conditions  hypersensitiveness  to  thermal  changes  may  de- 
velop, when  the  condition  becomes  pathologic.  Thermal  sensi- 
tiveness as  well  as  hypersensitiveness  of  dentin  is  often  developed 
during  the  progress  of  decay;  therefore,  in  the  preparation  of  cavi- 
ties for  fillings  we  find  few  teeth  the  dentin  of  which  is  without 
sensation.  This  fact  is  not  surprising,  nor  can  it  be  construed  as 
being  contrary  to  the  statement  that  normal  dentin  is  not  sensitive 
when  we  remember  that  there  are  few  teeth  in  the  mouths  of  patients 
demanding  the  services  of  the  dentist,  the  dentinal  fibrillae  and  pulps 
of  which  have  not  been  subjected  to  continued  irritation. 

Previous  Attempts  at  Controlling  Pain. — For  years  men  of  all 
classes,  from  the  conscientious  practitioner  to  the  charlatan  and 
quack,  have  endeavored  to  invent  means  or  discover  remedies  for 
the  elimination  of  pain  caused  by  operations  upon  vital  teeth.  In 
1836  Dr.  Spooner,  of  Montreal,  thought  he  had  made  the  discovery 
when  he  introduced  arsenic  trioxid  as  a  remedy  for  desensitizing 
dentin.  In  more  recent  years  cataphoresis,  high  pressure  injec- 
tion of  cocain,  interosseous  and  conductive  anesthesia  have  had 
their  advocates.  All  kinds  of  local  remedies  have  been  suggested. 
General  analgesia  by  chloroform  and  nitrous  oxid  has  long  been  used 
by  a  limited  number.  Later,  analgesia  by  somnoform  or  nitrous 
oxid  and  oxygen  has  been  revived.  Many  are  using  these  various 
agents  to-day  with  more  or  less  success — not  because  they  are  in 
full  sympathy  with  the  methods  or  means,  but  because  they  seem 
to  be  forced  to  use  something;  and  their  patients  are  willing  to 
submit  to  almost  any  process  if  pain  can  be  avoided. 

Any  method  or  remedy  for  the  elimination  of  pain  in  filling 
teeth,  which  necessitates  placing  the  tooth  or  patient  in  such  condi- 
tion that  the  dentin  can  be  painlessly  drilled  to  any  depth,  is  a 
dangerous  one  to  place  in  the  hands  of  the  profession  in  general. 
Pain  is  Nature's  indicator,  and  pain  should  be  our  guide.  The 
author  has  been  of  the  opinion  for  years  that  the  ideal  method  of 
desensitizing  dentin  would  be  the  application  of  a  remedy  within  the 
cavity  which  would  affect  the  dentin  only  to  a  given  depth,  and 
thereby  not  reach  nor  affect  the  pulp. 

In  the  discussion  of  means  and  methods  by  which  the  sensitive- 
ness of  the  dentin  can  be  allayed,  I  shall  not  attempt  to  enter  into 
the  details  of  the  many  histologic  and  pathologic  phenomena  which 
are  certain  to  arise  in  the  consideration  of  the  therapeutics  of  this 
subject,  but  shall  confine  myself  largely  to  the  drug  aspect. 


HYPERSENSITIVE   DENTIN       -  285 

The  sensitiveness  of  the  dentin  can  be  obtunded  in  no  small 
degree  by  the  use  of  various  therapeutic  agents;  and  I  might  state 
that  there  are  few  operations  which  we  are  called  upon  to  perform 
wherein  the  patient  will  appreciate  our  efforts  more  than  in  this  of 
applying  drugs  and  remedies  for  the  mitigation  of  pain.  But  in 
order  to  apply  intelHgently  and  successfully  any  remedy,  whether 
it  be  a  drug  or  an  agent,  to  the  dentin  and  thereby  obtund  the  sensi- 
tivity of  the  dentinal  fibrillae  without  endangering  the  vitaUty  of  the 
pulp  itself,  we  must  be  familiar  with  several  factors  or  conditions, 
which  I  cannot  with  propriety  here  discuss,  in  detail  at  least.  For 
instance,  a  thorough  knowledge  of  the  anatomic  and  histologic  struc- 
ture of  the  tooth  is  of  the.  highest  importance,  as  is  also  a  knowl- 
edge of  the  pathology,  not  only  of  the  fibrillae,  but  of  the  pulp  tissue 
as  well — the  changes  which  these  structures  are  capable  of  undergoing 
if  unduly  irritated  by  the  appUcation  of  the  remedy  employed.  Still 
another  factor,  of  equal  importance  and  one  which  more  directly 
relates  to  the  phase  of  the  subject  under  consideration,  is  a  knowl- 
edge of  the  pharmacologic  action  and  the  therapeutic  application^ 
of  the  drugs  and  remedies  used  for  this  purpose.  Before  using  a 
drug  or  an  agent  for  allaying  the  sensitiveness  of  dentin,  or  for  any 
other  purpose,  we  should  know  what  action  to  anticipate  from  its 
employment.  This  is  not  too  much  to  expect  from  the  trained 
dental  practitioner  of  to-day. 

THERAPEUTICS 

The  remedies  suggested  in  the  past  for  obtunding  sensitive  dentin 
have  been  many  and  varied.  ]  shall  discuss  only  those  which,  from 
clinical  experience,  have  proved  of  sufficient  value  to  merit  considera- 
tion; and,  for  convenience  of  study,  will  divide  them  into  four  general 
classes. 

I.  PHYSICAL  AGENTS 

There  are  some  physical  agents  by  the  proper  use  of  which  the 
sensitiveness  of  dentin  can,  in  a  measure,  be  obtunded.  The  most 
common  are: 

Heat.  Light. 

Gold.  Electricity. 

Heat. — The  appUcation  of  dry  heat  to  a  sensitive  cavity,  espe- 
cially in  conjunction  with  a  dehydrating  agent,  such  as  absolute 
alcohol,  is  always  an  aid ;  and  this  is  accomplished  by  means  of  heat- 
ing dry  air,  and  gently  directing  a  current  of  air  thus  heated  into 
the  cavity  which  has  been  isolated  by  the  rubber  dam  and  mois- 


286  PRACTICAL   DENTAL   THERAPEUTICS 

tened  with  the  dehydrating  agent  used.  Care  must  be  taken  not 
to  primarily  cause  pain,  otherwise  the  object  of  using  the  agent  would 
be  defeated. 

Several  apparatuses  have  been  devised  for  heating  the  air.  Dr. 
Rudolph  Beck  perfected  a  convenient  electrical  device  by  means  of 
which  compressed  air  can  be  heated  as  it  passes  through.  Other  such 
devices  are  on  the  market.  In  the  absence  of  these,  however,  the 
chip-blower  can  be  employed,  but  with  less  satisfaction.  Inasmuch 
as  heat  is  used  in  conjunction  with  another  and  more  important 
class  of  remedies,  I  shall  refer  to  this  agent  later. 

Cold. — This  is  another  physical  agent  sometimes  employed  for 
the  purpose  of  desensitizing  the  dentin.  Heat  may  be  abstracted 
from  the  tooth-structure  by  spraying  the  cavity  with  a  highly  vola- 
tile liquid,  like  ether,  rhigolene,  or  ethyl  chlorid.  In  the  use  of  these 
agents,  advantage  is  taken  of  the  physical  law  that  a  solid  in  changing 
.its  form  to  a  liquid,  or  a  liquid  in  changing  its  form  to  a  vapor  or  gas, 
must  abstract  from  the  thing  to  which  it  is  applied  a  certain  amount  of 
heat  in  order  to  effect  the  change.  Ether,  or  combinations  containing 
ether,  and  ethyl  chlorid,  both  used  as  sprays,  have  proved  valuable 
in  some  instances,  especially  in  shallow  cavities  near  the  gum  the 
dentin  of  which  is  difficult  to  obtund  by  the  usual  methods  employed 
heretofore,  and  to  which  reference  will  be  made  later. 

A  precaution  to  be  taken  to  prevent  primary  pain  in  applying 
this  remedy  is  to  fill  the  cavity  temporarily  with  stopping  and  direct 
the  spray  first  on  this  and  surrounding  parts,  after  which  the  stop- 
ping can  be  removed  and  the  spray  directed  into  the  cavity  without 
any  appreciable  pain.  The  degree  of  refrigeration  must  not  be  car- 
ried to  the  point  of  having  subsequently  a  possible  deleterious  effect 
upon  the  pulp  or  gum  tissue. 

A  practical  method  of  combining  dryness  and  cold  as  a  means  of 
obtunding  sensitive  dentin  has  been  suggested  by  Dr.  W.  T.  Reeves. 
It  consists  in  directing  a  small  jet  of  compressed  air  directly  into  the 
cavity  a  few  moments  before  operating,  and  keeping  it  up  during  the 
drilling  process.  To  prevent  primary  pain,  cotton  saturated  with  an 
analgesic  and  antiseptic  remedy  may  be  placed  in  the  cavity  first. 
The  air  serves  a  threefold  purpose ;  it  keeps  the  cavity  dry ;  clears  the 
field  from  chips;  and,  what  is  important  here,  it  lessens  the  heat  of 
drilHng  which  is  responsible  for  most  of  the  pain  in  cavity  preparar 
tion.  Those  inexperienced  with  the  method  must  be  careful  at  first, 
as  the  absence  of  pain  and  the  clear  field  may  lead  one  to  think  that 
the  bur  is  not  cutting;  as  a  result  one  is  liable  to  drill  deeper  thanjs 
absolutely  necessary. 


HYPERSENSITIVE   DENTIN  287 

Light. — This  agent  has  been  brought  forth  at  different  times  as 
having  a  peculiarly  favorable  effect  upon  hypersensitive  patients. 
In  one  method  the  rays  of  light  are  colored  by  passing  through  a 
blue  glass.  This  is  accompKshed  by  darkening  the  room  and  em- 
ploying a  blue  bulb  (i6  or  32  c.  p.)  on  an  ordinary  electric  socket. 
Whether  the  light  acts  locally  or  affects  the  vision  and  thus  the 
general  nervous  system  has  yet  to  be  demonstrated.  In  the 
author's  experience  with  this  agent  the  result  thus  far  has  not  been 
encouraging. 

Electricity. — The  electric  current  has  been  employed  as  a  means 
of  carr3dng  certain  drugs  into  the  dentin  and  pulp  tissue  for  obtun- 
dent purposes.  The  method  is  called  cataphoresis;  but  because  of  the 
expensive  and  compHcated  apparatus,  the  length  of  time  required  to 
obtund,  as  well  as  the  often  unsatisfactory,  and,  in  not  a  few  in- 
stances, disastrous  results,  the  method  has  generally  been  discarded. 

n.  ESCHAROTICS  OR  CAUSTICS 

Any  drug  or  agent  which  will  cauterize  the  dentinal  fibrillae,  will 
obtund  sensitive  dentin.  There  are  many  drugs,  however,  belonging 
to  this  class  that  cannot  be  used  for  this  purpose  because  of  their 
deleterious  effect  upon  both  the  tooth  structure  and  the  pulp  tissue. 
For  instance,  the  strong  mineral  acids  will  disorganize  the  proto- 
plasmic dentinal  fibrillae ;  but  they  will  also  disintegrate  the  inorganic 
structure  of  the  tooth.  Arsenic  trioxid  has  a  specific  poisonous 
action  upon  the  fibrillae,  but  there  is  no  known  means  of  preventing 
the  same  deleterious  effect  upon  the  cells  of  the  pulp  tissue. 

The  most  valuable  escharotics  for  desensitizing  the  dentin  are: 

Phenol.  Trichloracetic  Acid. 

Zinc  Chlorid.  Silver  Nitrate. 

Trioxymethylen. 

It  must  be  noted  that,  while  these  agents  will  obtund,  the  ultimate 
result  is  too  often  produced,  with  the  possible  exception  of  phenol, 
at  the  expense  of  quite  as  much  suffering  as  they  save. 

Phenol. — This  drug  has  local  analgesic  properties  besides  those  of 
a  cauterant,  and  will,  therefore,  be  discussed  under  another  and  more 
important  class  of  agents. 

Zinc  Chlorid. — Solutions  of  this  drug  of  various  strengths  can  be 
used  to  advantage  in  a  class  of  cavities  where  the  decay  or  softened 
dentin  does  not  extend  too  close  to  the  pulp.  Zinc  chlorid  coagulates 
albumin,  and  in  the  process  hydrochloric  acid  is  Uberated.  For  this 
reason  the  application  of  strong  solutions  is  painful  and  should  not 


255  PRACTICAL    DENTAL    THERAPEUTIC5 

be  resorted  to  in  deep  ca\'itie5  unless  the  irritating  action  of  the  agent 
is  modified.     This  can  be  done  to  a  marked  degree  by  selecting  alco- 
hol and  chloroform  as  the  vehicle  in  which  to  rnake  the  solution. 
A  useful  formula  is  here  given: 


R — Zinci  Chloridi,  gr.  xx  (1.3  Gm.) 

Alcoholis,  foiv  (i5-o  mils) 

Chloroformi,  q.  5.  ad.  foj  (30-0  mils) — M. 

Sig. — Apply  to  the  cavity  on  a  small  pledget  of  cotton  and 

gently  evaporate  to  dnmess. 
Xote. — If  the  zinc  salt  in  alcohol  does  not  niake  a  clear  solu- 
tion, it  indicates  that  some  of  the  salt  has  been 
oxidized;  the  solution  can  be  cleared  by  adding  one 
drop  of  dilute  hydrochloric  acid. 


This  is  an  excellent  remedy  to  apply  to  the  ca^'ity  immediately 
before  using  compressed  air. 

Trichloracetic  Acid. — In  concentrated  solution  trichloracetic  acid 
causes  considerable  pain  when  first  applied  to  a  sensitive  ca\aty, 
therefore  defeating  the  object  of  its  use;  but  in  a  10  or  15  per  cent. 
solution  it  produces  but  little  pain  or  inflammatory  reaction.  In 
this  strength  it  may  be  employed,  but  not  always  with  satisfactory 
results. 

Silver  Nitrate. — This  agent  is  perhaps  the  only  known  prophy- 
lactic drug  for  decay  of  tooth-structure.  In  the  posterior  part  of  the 
mouth  where  the  cementum  is  exposed  to  external  influences  and  thus 
is  sensitive,  or  in  shallow  ca\dties,  especially  in  children's  teeth,  the  use 
of  this  drug,  in  the  soHd pencil  form  or  in  solutions  of  varying  strength, 
T^dll  be  found  valuable,  both  as  a  means  of  reducing  the  sensitiveness 
and  preventing  further  ingress  of  caries.  As  an  agent  for  obtunding 
the  sensiti\dty  of  the  dentin  in  an  ordinary  cavity  it  should  not  be 
considered,  for  various  reasons.  When  the  agent  is  employed  for 
the  purposes  above  mientioned,  the  ca^dty,  after  the  application, 
should  be  kept  free  from  saliva  for  a  few  minutes,  and.  if  possible, 
exposed  to  sunHght,  thus  decomposing  the  silver  salt  as  referred  to 
under  the  subject  of  Light  (see  p.  252).  A  solution  of  sodium  chlorid 
should  always  be  at  hand  when  using  silver  nitrate,  and  in  case  any 
of  the  latter  agent  should  accidentally  get  on  the  mucous  membrane 
of  the  patient's  mouth  its  action  can  be  checked  at  once  by  rinsing 
the  mouth  -vNdth  this  antidotal  solution. 

TrioxjTuethylen. — The  use  of  this  drug  for  desensitizing  pur- 
poses will  be  mentioned  later  under  Desensitizing  Paste. 


HYPERSENSITIVE   DENTIN  289 

m.  LOCAL  ANODYNES  OR  LOCAL  ANESTHETICS 

In  the  judicious  use  of  agents  belonging  to  this  class  the  author 
firmly  believes  will  ultimately  be  found  the  surest  and  safest  road  to 
success.  This  statement  stands  as  it  first  appeared  in  this  book 
(1909).  Subsequent  investigation  by  the  author,  which  will  be  re- 
ferred to  later  under  Desensitizing  Paste,  has  proven  the  correctness 
of  the  statement.  The  following  agents,  or  a  combination  of  two  or 
more,  will  be  found  to  be  of  the  utmost  value : 

Cocain.  Eugenol. 

Novocain.  Phenol. 

Neothesift:  Ethyl  Chlorid. 

Menthol.  Ether. 

Oil  of  Cloves.  Chloroform. 

Cocain. — Both  the  alkaloid,  cocain,  and  the  alkaloidal  salt,  cocain 
hydrochlorid,  are  used  in  various  ways  for  obtunding  sensitive  dentin. 
An  important  physiologic  property  of  cocain  to  be  remembered  here 
is  its  power,  when  applied  directly  to  the  mucous  membrane  or  when 
injected  or  forced  into  the  pulp  tissue,  of  inducing  a  condition  of 
analgesia  in  the  part  by  paralyzing  the  sensory  nerve  filaments. 
In  addition  to  this,  it  causes  a  blanching  of  the  part  which  is  subse- 
quently followed  by  congestion.  It  should  also  be  remembered 
that  pharmacologists  have  proved  beyond  a  doubt  that  cocain  is  a 
general  protoplasmic  poison;  that  muscles  as  well  as  nerves  and  nerve- 
ends  cease  to  contract  or  to  conduct  stimuli  when  they  are  exposed 
to  even  dilute  solutions  of  the  drug.  The  only  reason  why  the  dele- 
terious effect  is  more  noticeable  upon  nerve  than  upon  other  kinds 
of  tissue  is  that  here  we  are  deaHng  with  the  medium  of  sensation 
and  expression. 

The  author  deems  it  wise  to  call  attention  to  these  well-estab- 
lished physiologic,  pharmacologic  and  pathologic  facts,  for  many 
instruments  have  been  devised  for  forcing  solutions  of  cocain  hy- 
drochlorid of  various  strengths,  not  only  into  the  dentinal  tubuli, 
thereby  paralyzing  the  fibrillae,  but  into  the  pulp  proper,  anesthetizing 
this  organ  as  well.  In  view  of  these  facts,  it  would  appear  that  we 
are  seldom  justified  in  completely  anesthetizing  the  pulp  of  a  tooth  for 
the  purpose  oj  painlessly  preparing  a  cavity  therein.  Therefore, 
under  the  subject  of  Cataphoresis  previously  referred  to,  little  was 
written;  and,  for  the  same  reasons,  the  method  of  anesthetizing  the 
pulp  by  high- pressure,  interosseous,  or  conductive  anesthesia  for 
obtundent  purposes  only  will  not  be  considered.  These  methods 
will  be  discussed  subsequently  under  Pulp  Removal. 


290  PRACTICAL   DENTAL   THERAPEUTICS 

Cocain  and  the  alkaloidal  salt,  cocain  hydrochlorid,  are  safe 
and  reliable  agents  for  obtunding  sensitive  dentin,  if  confined  to  the 
dentinal  structure  of  the  tooth.  Frequently,  in  deep-seated  cavi- 
ties, especially  in  children's  teeth,  the  sensitiveness  can  be  com- 
pletely overcome  by  sealing  in  the  cavity  for  a  day  or  two  a  creamy 
paste  made  by  mixing  the  alkaloid  with  liquid  petroleum.  The 
oleate  of  cocain  (N.F.)  can  also  be  used  for  this  purpose.  The  paste 
or^oleate  should  cover  the  entire  surface  of  dentin  which  we  subse- 
quently expect  to  excavate.  Good  results  can  also  be  immediately 
obtained  by  the  use  of  the  following  remedy: 

I^ — Cocainae,  gr.  xx  (1.3  Gm.) 

Chloroformi,  f5ij  (8.0  mils) 

Etheris,  q.  s.  ad.       foj  (30.0  mils). — M. 

Sig. — After  the  rubber  dam  has  been  adjusted,  apply  to  the 
cavity  on  a  small  pledget  of  cotton  and  evaporate  to 
dryness. 

In  the  use  of  this  remedy,  advantage  is  taken  of  the  physical  law 
previously  referred  to  in  connection  with  Cold.  As  the  volatile 
liquids,  ether  and  chloroform,  evaporate,  a  certain  amount  of  heat 
is  abstracted  from  the  tooth-structure,  and  a  coating  of  the  alkaloid, 
driven  to  an  extent  into  the  dentin,  is  left  in  the  cavity.  This 
remedy  will  not  completely  obtund  all  sensitive  dentin,  but  its  use 
will  be  a  material  aid. 

There  can  be  no  objection  in  favorable  cases,  provided  the  dentin 
has  been  previously  sterilized,  to  using  aqueous  solutions  of  cocain 
hydrochlorid  with  uniform  pressure  over  the  entire  area  of  the 
cavity,  thus  forcing  the  anesthetizing  solution  an  equal  distance 
into  the  dentin.  This  is  an  extremely  difficult  thing  to  do  without 
forcing  the  solution  at  some  more  favorable  point  in  the  cavity 
through  the  tubuH  and  into  the  pulp.  However,  there  are  cavities 
where  good  results  can  be  accomplished  by  the  careful  use  of  this 
method.  In  some  cases  of  gingival  cavities  good  results  can  be 
obtained  by  hypodermically  injecting  a  i  to  1.5  per  cent,  solution  of 
cocain  hydrochlorid  into  the  pericemental  membrane  somewhere 
near  the  apex  of  the  root.  This  practice  should  not  be  generally 
recommended. 

Novocain. — This  drug  may  be  substituted  for  cocain  and  used 
as  above  described.  Its  action  is  much  slower;  and,  for  the  pur- 
poses mentioned,  it  possesses  no  advantages.  Sterile,  isotonic 
solutions  are  recommended  to  be  used  hypodermically  for  hyper- 
sensitive dentin.     The  drug  is  injected  by  the  infiltration,  inter- 


HYPERSENSITIVE   DENTIN  29I 

osseous,  and  conductive  anesthesia  methods  (see  pp.  130  and  138, 
and  works  on  Local  Anesthesia.) 

Neothesin. — The  use  of  this  agent  in  combination  with  other 
drugs  for  desensitizing  dentin  will  be  considered  later. 

Menthol. — This  drug  can  be  substituted  for  the  cocain  in  the 
above  prescription  with  ether  and  chloroform,  and  used  in  exactly 
the  same  manner.  An  oily  liquid  (mentho-chloral)  can  be  formed 
by  heating  together  over  a  water-bath,  or  rubbing  in  a  mortar,  an 
equal  amount  of  menthol  and  chloral.  This  remedy  will  be  found 
ef&cacious  by  seaHng  in  the  cavity  for  a  few  days. 

Oil  of  Cloves. — ^A  profound  analgesic  effect  can  be  produced 
upon  sensitive  dentin,  especially  in  deep-seated  cavities,  by  using  oil 
of  cloves  and  heat  in  the  following  manner,  as  suggested  by  Dr. 
C.  N.  Johnson:  After  carefully  desiccating  the  dentin  by  means 
of  warm  alcohol  and  gentle  heat,  a  pledget  of  cotton  saturated  with 
oil  of  cloves  should  be  placed  in  the  cavity  and  a  current  of  heated 
dry  air  directed  thereon  until  the  cotton  is  nearly  dry.  This  should 
be  repeated  as  often  as  the  case  demands. 

Eugenol. — Eugenol  is  the  chief  constituent  of  oil  of  cloves  and 
can  be  used  in  the  same  manner  as  the  latter  drug,  as  above  de- 
scribed. 

Phenol. — This  drug  can  be  substituted,  with  equally  good  results, 
for  the  oil  of  cloves  or  eugenol,  as  described  in  the  foregoing  method. 
Care  should  be  taken  here,  however,  in  directing  the  heated  air, 
that  the  fumes  of  phenol  do  not  escape  in  the  patient's  face.  Oil 
of  cloves,  eugenol,  and  phenol  are  three  true  local  anodynes^  any  one 
of  which,  if  hermetically  sealed  in  a  cavity  for  a  few  weeks,  will 
check  the  continued  irritation  of  the  fibrillae  and  pulp,  and  thus  aid 
Nature  to  restore  these  structures  to  their  normal  condition  when 
they  should  not  be  responsive.  The  author's  phenol  compound  (see 
p.  3 1 1)  is  an  excellent  remedy  for  this  latter  purpose.  By  this  means, 
then,  the  sensitiveness  of  the  dentin  can  also  be  allayed. 

Ethyl  Chlorid,  Ether,  and  Chloroform. — These  agents,  by  their 
extreme  volatility,  produce  a  condition  of  analgesia,  thereby  obtund- 
ing  sensitive  dentin,  as  previously  explained  under  Cold. 


IV.  GENERAL  ANODYNES  OR  ANALGESICS 

Before  the  introduction  of  Desensitizing  Paste  and  the  modern 
and  improved  methods  of  using  local  anesthetics,  it  was  sometimes 
necessary  in  order  to  do  permanent  work  for  certain  highly  nervous 


292  PRACTICAL   DENTAL   THERAPEUTICS 

patients  to  resort  to  the  administration  of  this  class  of  drugs.     The 
agents  largely  used  for  this  purpose  are: 

Opium.  Nitrous  oxid. 

The  bromids.  Chloroform. 

Opium. — This  drug  is  a  most  powerful  analgesic,  and  while  there 
are  some  dental  conditions  where  it  or  its  chief  alkaloid,  morphin, 
is  truly  indicated,  the  drug  ought  not,  in  the  author's  judgment,  to 
be  given  for  the  treatment  of  sensitive  dentin. 

The  Bromids. — The  bromids  of  potassium,  sodium,  and  ammo- 
nium are  valuable  drugs  in  certain  cases.  Perhaps  there  is  no  drug 
which  will  quiet  a  nervous  patient  more  readily,  when  the  nervous- 
ness comes  purely  from  fear  or  dread,  than  potassium  bromid,  which 
is  the  representative  of  this  class.  In  such  cases,  where  it  is  deemed 
necessary,  the  following  prescription  will  prove  helpful: 

I^ — Potassii  bromidi,  3jss  (6.0  Gm.) 

Syrupi  sarsaparillae  comp.,  fgiij  (90.0  mils.) — M. 
Sig. — Take  a  tablespoonful  in  water  after  meals  the  day  before 
coming  to  the  office. 

Nitrous  Oxid. — There  are  varying  apparatus  on  the  market 
by  which  nitrous  oxid  gas  can  be  administered  through  the  nose. 
It  is  possible  with  such  an  apparatus  to  carry  the  patient  just  to 
the  analgesic  stage,  and  hold  him  under  its  influence  until  a  sensi- 
tive cavity  has  been  painlessly  prepared.  Oxygen,  in  proper  pro- 
portions, is  generally  mixed  with  the  anesthetic  agent  for  this  pur- 
pose, as  it  overcomes  the  cyanosis  which  frequently  follows  the 
prolonged  use  of  nitrous  oxid  alone.  In  cases  where  the  operator 
feels  that  it  is  necessary  to  resort  to  this  method,  good  results  can 
be  accomplished. 

Chloroform. — With  the  patient  in  the  upright  position,  chloro- 
form can  be  carried  to  the  analgesic  stage  and  sensitive  cavities 
prepared.  Most  authorities  agree,  however,  that  chloroform  should 
not  be  administered  unless  the  patient  is  in  the  recumbent  position, 
and  that  the  analgesic  stage  is  the  most  dangerous.  Death  has  been 
known  to  occur  suddenly  after  a  few  inhalations  in  cases  of  marked 
idiosyncrasy  against  the  drug. 

Hewitt,  De  Ford,  and  others  report  excellent  results  from  the  use 
of  chloroform  in  the  manner  described  above.  In  selected  cases  the 
author  has  used  the  method  with  uniformly  good  results;  but  the 
general  use  of  the  drug  in  this  manner  is  not  advised. 


HYPERSENSITIVE   DENTIN  293 

DESENSITIZING  PASTE 

Desensitizing  Paste  is  a  preparation  introduced  by  the  author 
to  the  profession  as  an  absolute  specific  for  hypersensitive  dentin. 
The  formula  contains  neothesin,  th}Tnol  and  trioxymethylen,  in 
the  proportion  of  ii,  12  and  77  parts,  respectively;  all  combined 
with  a  petroleum  base,  and  incorporated  in  a  fibrous  vehicle  and 
colored  with  an  insoluble  pigment.  One  grain  of  the  preparation  is 
sufficient  for  about  fifteen  applications.  On  this  basis  the  amount 
necessary  for  one  application  contains  neothesin  J-^oo  gr-,  thymol 
3^70  gr.,  and  trioxymethylen  3^3  gr.  The  use  of  the  remedy  in 
the  hands  of  careful  operators  is  safe  and  absolutely  reliable.  In 
the  hands  of  careless  operators  no  effective  remedy  or  method  of 
desensitizing  dentin  is  safe.  The  dental  pulp  is  a  delicate  and 
highly  susceptible  organ,  and  it  must,  therefore,  be  handled  with 
intelligence  and  care.  Most  patients  who  repose  confidence  in 
the  operator  are  sensible,  and  are  willing  to  endure  some  pain  in  the 
preparation  of  cavities  in  their  teeth.  With  confidence,  a  true 
running  engine,  a  sharp  bur,  a  dry  cavity,  a  steady  hand,  and  a 
knowledge  of  what  ought  to  be  done  in  a  given  case,  it  is  not 
necessary  to  use  Desensitizing  Paste  or  any  other  absolute  and 
positive  means  of  desensitizing  the  dentin  in  every  case  which  pre- 
sents. Yet,  it  must  not  be  forgotten  that  the  preparation  of 
cavities  in  vital  teeth  without  some  means  of  obtunding  the  dentin 
more  positively  than  has  been  done  in  the  past,  is  generally  a  pain- 
ful operation  which  is  dreaded  by  most  patients. 

In  his  work  on  "Operative  Dentistry,"  published  in  1908,  on 
page  149,  Dr.  G.  V.  Black  says:  "The  treatment  of  sensitive  dentin 
for  the  purpose  of  relieving  or  limiting  the  pain-in  the  excavation  of 
cavities  has  been  prominently  before  the  dental  profession  since  the 
first  discovery  of  anesthesia,  and,  perhaps,  for  many  years  before  that 
time.  Personally,  I  have  watched  the  progress  of  this  effort  through 
many  years  of  what  has  been  fairly  close,  careful  observation  in 
clinical  practice,  and  always  with  an  earnest  desire  to  reHeve  patients 
of  suff'ering  in  the  necessary  cutting  in  the  preparation  of  ca\dties. 
In  all  of  this  time,  and  up  to  the  present,  the  results  have  been  so 
poor,  or  so  uncertain,  that,  as  compared  w^th  skillful  use  of  well- 
selected  cutting  instruments,  well-tempered  and  always  sharp,  they 
have  not  been  a  success."  The  author  concludes  by  saying:  "But 
the  relief  of  suffering  is  an  ever-present  duty,  and  the  search  for  this 
very  desirable  thing  should  continue." 

Physiologic  Action. — It  is  highly  essential  that  we  understand 
how  desensitization  is   brought  about  when  Desensitizing    Paste 


294  PRACTICAL   DENTAL   THERAPEUTICS 

is  applied  to  the  dentin.  The  neothesin  applied  directly  to  the 
exposed  sensitive  dentinal  fibrillae  acts  quickly  thereon  and  tempo- 
rarily paralyzes  the  ends  thus  exposed.  The  thymol  volatilizes  and 
permeates  the  softened  dentin.  The  heat  of  the  body  gradually 
Uberates  formaldehyd  from  the  trioxymethylen,  which  gas  diffuses 
through  the  decayed  dentin,  combining  chemically  with  the  amine 
group  of  the  protein  constituent  of  the  dentinal  fibrillae.  The 
formaldehyd  also  acts  upon  certain  intermediate  and  end-products 
that  may  be  present  in  the  carious  tooth-structure  as  a  result  of 
albuminous  decomposition,  and  this  agent,  together  with  the  thymol, 
brings  about  complete  sterilization.  Thus  the  dentin  affected  by  the 
remedy  is  not  only  desensitized,  but  sterilized  as  well,  which  is  an 
all-important  factor.  The  vitality  of  the  fibrillae  is  destroyed  in 
the  area  affected,  but  the  remedy  will  not  affect  sound  dentin  to 
any  dangerous  depth.  In  the  preparation  of  the  cavity,  in  the 
average  case,  the  dentin  affected  by  the  remedy  is  practically  all 
removed.  If  it  is  not,  I  know  from  my  experience  with  the  prepara- 
tion that  the  vitality  of  the  fibers  is  subsequently  restored,  for  after 
a  few  weeks  sensation  returns.  While  this  regeneration  is  being 
brought  about,  the  tooth  may  develop  slight  thermal  sensitiveness 
which  lasts  for  about  a  week.  This  occurs  only  in  a  small  per- 
centage of  cases.  It  is  mentioned  here  simply  that  the  operator 
may  know  the  cause,  and  that  should  such  sensitiveness  develop, 
it  will  be  of  short  duration. 

Indications. — Desensitizing  Paste  may  be  used  with  perfect 
safety  in  all  cases  of  hypersensitive  dentin  where  the  pulp  of  the 
tooth  is  not  diseased  to  the  extent  of  necessitating  the  removal  of 
the  organ  because  of  its  pathology.  As  has  previously  been  men- 
tioned, it  is  not  necessary  to  employ  the  remedy  in  every  case  of 
cavity  preparation.  Where  the  pain  is  not  great,  and  where  the 
patient  is  willing  to  endure  the  small  amount,  no  therapeutic  remedy 
is  needed;  but  every  dentist  has  cases  in  which  it  is  impossible 
to  do  satisfactory  work  because  of  the  hypersensitiveness  of  the 
dentin.  In  all  such  cases  the  use  of  Desensitizing  Paste  will  prove 
a  blessing  to  humanity  and  a  godsend  to  those  earnest  practitioners 
who  have  grown  gray  and  nervous  standing  at  their  chairs  trying 
to  properly  prepare  cavities  in  the  teeth  of  hypersensitive  patients. 

Making  the  Application. — In  employing  Desensitizing  Paste,  it 
is  not  necessary  to  remove  any  of  the  carious  dentin  that  is  at  all 
sensitive.  To  attempt  this  often  causes  pain,  and  the  remedy,  if 
used  at  all,  is  intended  to,  and  will,  absolutely  eliminate  all  pain  in 
cavity  preparation.     The  cavity  and  immediate  tooth-surface  should 


HYPERSENSITIVE   DENTIN 


295 


be  dried  with  alcohol  and  a  small  amount  of  the  paste  sealed  therein 
with  a  good  cement.  Better  results  will  be  obtained  if  the  remedy 
is  spread  over  the  cavity  surface.  This  can  be  accomplished  with 
a  ball  of  cotton  held  in  the  phers.  In  gingival  cavities,  such  as 
is  illustrated  in  Fig.  3,  it  is  often  necessary  to  flow  the  cement  over 
the  enamel  surface,  depending  entirely  on  its  adhesiveness  to  hold 
the  paste  on  the  softened  tooth-structure. 

Twenty-four  to  forty-eight  hours  is  sufficiently  long  to  bring 
about  complete  desensitization,  and  this  is  the  proper  length  of 
time  to  leave  the  remedy  sealed  in  a  tooth.  However,  no  harm  will 
follow  if  the  paste  should  remain  in  the  tooth  for  a  longer  period. 
The  small  amount  employed  will  soon  exert  its  full  influence,  after 


Fig.  3. — Prepared  cavity. 

which  no  further  action  follows.  An  effort  should  be  made  to 
hermetically  seal  all  the  margins  of  the  cavity — thus  confining  the 
action  of  the  remedy  to  the  dentin.  This  is  sometimes  difficult  to 
do  with  gingival  cavities.  If  it  is  not  accomplished,  a  certain 
amount  of  the  formaldehyd  gas  may  escape  as  it  is  liberated,  in 
which  case  the  dentin  would  not  be  profoundly  affected. 

When  it  becomes  necessary  to  prepare  a  cavity  in  practically 
sound  dentin,  as  is  frequently  the  case  for  bridgework  and  in  super- 
ficial cavities,  it  may  be  necessary  to  make  a  second  application  of 
the  paste  in  order  to  prevent  any  pain.  In  all  cases  where  there  is 
considerable  decay,  one  appHcation  will  be  sufficient  to  desensitize 
the  entire  cavity.  The  depth  to  which  the  dentin  is  affected  by  the 
remedy  will  depend  upon  the  condition  of  the  dentin.  In  using 
Desensitizing  Paste  it  will  be  found  that  in  about  5  to  10  per  cent, 
of  all  cases  the  teeth  to  which  it  has  been  applied  with  grumble  or 
have  a  tendency  to  ache.  If  the  remedy  has  been  used  where  indi- 
cated, no  alarm  need  be  felt  because  of  this,  for  it  will  subside  in 
a  few  hours. 

Precautions. — There  are  no  special  precautions  to  be  observed 
in  using  Desensitizing  Paste,  so  far  as  the  remedy  itself  is  concerned. 


296  PRACTICAL   DENTAL    THERAPEUTICS 

It  will  not  even  destroy  normal  gum  tissue  to  any  appreciable  extent, 
at  least,  if  sealed  in  contact  with  it.  It  will  be  necessary,  however, 
for  the  dentist  who  desires  to  use  this  remedy  intelligently  to 
so  school  himself  in  pulp  pathology  that  the  remedy  may  not  be 
used  in  those  cases  where  the  reading  of  the  clinical  symptoms  would 
clearly  indicate  the  removal  of  the  pulp. 

In  deep-seated  cavities  which  approximate  the  pulp,  yet  where 
the  organ  is  not  diseased  to  the  extent  of  necessitating  its  removal, 
the  paste  need  not  be  applied  to  the  entire  cavity.  In  these  cases 
very  small  doses  may  be  placed  over  such  areas  only  as  will  need 
to  be  drilled  subsequently  in  the  cavity  preparation,  and  some 
anodyne  remedy  like  phenol  compound  placed  immediately  over  the 
pulp.  The  danger  in  using  this  preparation  does  not  He  in  the 
possibility  of  affecting  deleteriously  a  healthy  pulp,  provided  there 
is  sound  dentin  between  the  bottom  of  the  cavity  and  the  pulp 
proper,  but  rather  in  the  probabiHty  of  diseased  pulps  being  left  in 
teeth  to  die  and  putrefy,  because  of  the  absence  of  sensation  in  the 
dentin  after  the  remedy  has  been  used.  The  decision,  therefore, 
as  to  whether  or  not  the  pulp  is  diseased  and  removal  necessary 
should  be  made  before  employing  Desensitizing  Paste. 

In  my  clinical  experiments  I  have,  at  times,  purposely  used 
the  paste  in  cavities  of  extensive  decay,  where  I  suspected  the  pulp 
was  affected.  At  the  subsequent  sitting  I  was  able  to  painlessly 
remove  all  of  the  carious  dentin  which  extended  very  nearly,  and  in 
some  cases  quite  to  the  pulp.  In  cases  where  the  pulp  was  exposed 
it  was  found  to  be  sensitive  and  would  bleed  freely,  indicating,  to 
my  mind,  that  it  had  not  been  affected  by  the  remedy.  However, 
it  is  our  plain  duty  in  such  cases  as  these  to  remove  the  pulp,  for 
I  do  not  believe  that  decay  can  extend  to  or  nearly  to  the  pulpal 
organ  without  the  latter  being  affected  by  the  carious  process,  if 
not  infected  by  the  germs  present  in  the  cavity. 

Caution  in  Relation  to  Diseased  Pulps. — In  detailing  the  use 
of  this  valuable  remedy  I  wish  specifically  to  call  attention  to  the 
fact  that  every  dentist  has  had  cases  in  his  practice  where  vital 
teeth  have  ached  after  permanent  fillings  have  been  inserted,  and 
that  pulps  occasionally  die  following  these  operations.  Unless  the 
dentist  is  well  posted  on  pulp  pathology  and  is  cautious  in  his  diag- 
nosis similar  experiences  will  follow  the  use  of  Desensitizing  Paste. 
If  such  should  be  the  case,  however,  it  will  be  through  no  fault  of 
the  remedy — it  will  be  the  fault  of  mistaken  diagnosis.  I  can  under- 
stand how  much  harm  may  follow  the  use  of  any  remedy  or  method 
by  which  cavities  can  be  painlessly  prepared.     In  the  hands  of  the 


HYPERSENSITIVE   DENTIN 


297 


careless  operator  pulps  may  be  left  in  which  should  have  been  removed. 
In  the  hands  of  that  great  army  of  conscientious  practitioners,  who 
constitute  the  vast  majority,  Desensitizing  Paste  will  lighten  their 
burdens  and  prove  its  worth  (Fig.  4). 


Fig.  4. 

Fig.  4. — This  radiograph  was  taken  of  one  of  the  first  cases  in  which  the  author  used 
Desensitizing  Paste  in  his  practice.  The  patient  was  a  girl  about  fourteen  years  of 
age  whose  teeth  were  extremely  hj^^er sensitive  and  decayed  rapidly.  On  account  of 
the  nervousness  of  the  little  patient  and  the  hypersensitiveness  of  the  dentin,  only  tem- 
porary work  could  be  done.  This  first  lower  bicuspid  erupted  when  the  child  was  seven 
years  old,  and  began  to  decay  at  once.  As  will  be  noticed  it  is  a  malformed  tooth. 
A  small  mesial  cavity  had  been  filled  with  amalgam.  The  larger  distal  cavity  was  filled 
several  times  with  cement. 

Desensitizing  Paste  was  applied  on  April  3,  19 14.  The  following  day  the  cavity  was 
prepared  absolutely  without  pain  in  the  presence  of  several  dentists  during  the  "Office 
Clinics"  held  in  connection  with  the  Fiftieth  Anniversary  of  the  Illinois  State  Dental 
Society. 

The  cavity  was  subsequently  filled  with  porcelain.  On  account  of  lack  of  proper 
anchorage:  (over  one-half  of  crown  was  gone)  this  filling  came  out  the  following  January. 
I  decided  to  fill  the  cavity  with  synthetic  porcelain.  Upon  drilling  for  anchorage, 
the  dentin  was  as  sensitive  as  though  it  had  never  been  completely  desensitized.  The 
radiograph  was  taken  April  3,  1916,  two  years  after  desensitization;  and  the  tooth  has 
been  tested  for  vitality  every  few  months  with  the  electric  current.  The  case  is  one  of 
hundreds  in  the  author's  practice  which  prove  that,  properly  used,  Desensitizing  Paste 
will  not  kill  the  dental  pulp. 

In  closing,  I  want  to  say  that  the  dread  of  the  dental  chair,  the 
severe  nervous  strain  upon  dentists,  the  failure  of  operative  pro- 
cedures upon  vital  teeth  and  the  ruthless  destruction  of  the  dental 
pulp,  with  its  frequent  evil  sequelae,  have  been  more  largely  due  to 
hypersensitive  dentin  than  to  all  other  causes  combined.  It  is  a  great 
pleasure  and  satisfaction,  therefore,  for  the  author  to  here  discuss 
the  uses  of  Desensitizing  Paste  in  connection  with  the  therapeutics 
of  this  condition. 


DIAGNOSIS   AND    TREATMENT    OF    DISEASES    OF    THE 

DENTAL  PULP;  INCLUDING  THE  DESTRUCTION 

AND  REMOVAL  OF  THE  ORGAN 

GENERAL  CONSIDERATIONS 

In  the  treatment  of  the  dental  pulp,  as  in  all  other  therapy,  it 
is  highly  essential  that  we  differentiate  between  the  various  kinds 
of  diseases  of  this  organ,  and  by  means  of  reasoning,  using  com- 
mon sense  and  judgment,  and  the  process  of  exclusion,  arrive  at 
a  correct  diagnosis  before  applying  our  therapeutics.  Any  other 
method  of  procedure  is  Httle  short  of  guesswork;  and  we  must 
admit  that  there  has  been  too  much  guessing  at  results,  on  the  part 
of  many,  in  the  dental  therapeutics  of  the  past.  In  order  to  correct 
this  evil  we  should  delve  more  deeply  into  the  science  of  pathology, 
and  then,  learning  to  properly  interpret  the  clinical  manifestations 
of  these  various  diseases,  we  can  select  and  apply  our  remedies  along 
more  rational  lines. 

The  Normal  Dental  Pulp. — To  know  a  tissue  or  organ  in  disease 
one  must  first  know  it  in  health.  Therefore,  let  us  briefly  review 
the  anatomy  and  physiology  of  the  dental  pulp  (Fig.  5).  Our  his- 
tologists  inform  us  that  this  organ  is  the  remains  of  the  original 
dental  papilla,  changed  somewhat  to  meet  its  present  environment, 
and  is  composed  of  soft  embryonal  connective  tissue,  with  an  outer 
layer  of  odontoblastic  cells,  the  whole  being  well  supplied  with 
blood-vessel  and  nerves.  The  blood-vessels  of  the  pulp  are  sup- 
posed to  communicate  with  the  general  circulation  through  the 
apical  foramen  or  foramina  of  the  tooth.  One  or  more  small  arterial 
trunks  enter  the  pulp  cavity  at  the  apex,  and,  coursing  occlusally 
through  the  center  of  the  tissue,  give  off  many  branches.  Near 
the  occlusal  end  of  the  pulp  they  further  divide  into  capillaries,  and 
form  a  fine  plexus  around  the  peripheral  portion  of  the  pulp.  The 
blood-vessels  are  generously  distributed  through  the  tissue.  The 
veins  form  a  similar  plexus,  and  a  central  vein,  analogous  to  the 
artery,  receives  the  blood  from  these  many  venules  and  conducts  it 
through  the  apical  foramen.  The  nerves  of  the  pulp  are  transmitted 
through  the  apical  foramina  together  with  the  blood-vessels.  Several 
bundles  of  medullated  nerve  fibers  enter  the  foramen  and  break  up 
into  a  plexus  of  nerves,  which  are  widely  distributed  through  the 
pulp  tissue  (Turner). 


Lines  of  Schreger. 

Lines  of  Retzius. 

Enamel  rods. 
Enamel. 

Dentin. 
Dentinal  tubuli. 

Dental  pulp. 

— '  Odontoblasts. 

"  Epithelium. 

Principal  fibers. 

Interglobular  spaces. 

Cementum. 

Pericementum. 

Cement  corpuscles. 

Tomes's  granular  layer. 

Bone  trabecule. 

Bone. 

Pulp  cells. 

Arteries,  veins,  nerves. 

Periosteum. 


Multiple  foramina. 


Fig.  5.— Showing  histology  of  the  normal  tooth  and  supporting  structures. 


TREATMENT    OF    DISEASES    OF    THE   DENTAL   PULP  299 

.  Character  of  Blood-vessels. — The  walls  of  the  pulpal  blood-vessel 
are  unusually  thin.  The  arteries  are  found  to  be  almost  devoid 
of  the  external  fibrous  coat;  and,  according  to  Noyes,  the  muscular 
layer  is  represented  by  a  single  involuntary  fiber,  while  the  walls  of 
the  veins  are  formed  by  a  single  layer  of  endothelial  cells.  It  has 
long  been  known  that  the  pulp  tissue,  like  the  brain,  contains  no 
lymphatics,  and  when  we  recall  the  thinness  of  the  walls  of  the 
blood-vessels  and  that  the  organ  is  confined  within  a  cavity  having 
unyielding  walls,  the  absence  of  lymphatics  becomes  of  the  greatest 
pathologic  significance. 

Common  Sources  of  Irritation.- — Before  taking  up  the  pathology 
of  the  pulp,  let  us  consider  for  a  moment  some  of  the  more  common 
sources  of  irritation  of  this  organ  and  pericemental  membrane,  due 
to  ignorance  or  carelessness,  or  both,  on  the  part  of  dentists.  So 
far  as  drugs  are  concerned,  I  am  of  the  opinion  that  alcohol  causes 
more  irritation  to  these  structures  than  any  other  one  remedy. 
Ethyl  alcohol,  95  per  cent.,  is  a  most  excellent  agent,  but  a  much 
abused  one  in  dental  practice.  For  removing  the  gelatinous  coating 
and  steriHzing  the  crowns  of  teeth  included  in  the  rubber  dam,  it 
is  invaluable,  but  it  is  never  necessary  to  use  alcohol  in  this  strength 
to  desiccate  or  sterilize  the  dentin  of  a  cavity  in  a  vital  tooth  which 
we  desire  to  fill,  or  for  desiccating  a  canal  previous  to  the  insertion 
of  a  root-filling.  That  these  results  can  be  accomplished  by  using 
this  agent,  no  one  will  deny;  but,  if  we  will  only  stop  to  consider, 
we  must  also  know  that  the  results  are  too  frequently  obtained  at 
the  expense  of  irritation  of  the  pulp  and  tissue  in  the  periapical 
region.  I  know  that  the  use  of  95  per  cent,  alcohol  for  such  purposes 
has  long  been  an  estabHshed  practice,  and  how  startHng  and,  to 
some  perhaps,  unfounded  these  statements  may  appear;  but,  never- 
theless, I  know  too  that  these  indictments  against  the  indiscrimi- 
nate use  of  alcohol  in  the  treatment  of  teeth  are  justifiable,  when 
we  are  considering  the  etiology  of  these  diseases.  What  then  shall 
we  use  as  a  substitute?  My  answer  is  to  use  either  alcohol  modified, 
which  is  70  per  cent,  alcohol  and  30  per  cent,  water,  to  which  solu- 
tion I  gr.  of  thymol  is  added  to  each  fluidounce;  or  a  10  per  cent. 
alcohoHc  solution  of  phenol  compound,  or  some  other  remedy  ha\'ing 
similar  properties — those  of  desiccant,  anodyne  and  disinfectant. 
The  popular  behef  is  that  phenol  is  hke  an  oil  and  that  it  is  neces- 
sary to  follow  its  use  in  a  cavity,  for  example,  mth  ethyl  alcohol 
in  order  to  have  the  cement  adhere.  This  is  an  erroneous  idea. 
Phenol,  though  oleaginous  in  its  physical  appearance,  is  not  an  oil, 
any  more  than  is  sulphuric  acid  which  is  also  oleaginous  in  character. 


300  PRACTICAL   DENTAL   THERAPEUTICS 

Phenol  is  an  alcohol  and  can  be  evaporated  with  warm  air  almost  as 
readily  as  ethyl  alcohol,  and  absolutely  without  irritation  (pain) 
of  the  tissues  involved. 

Still  another  common  and  fruitful  source  of  pulp  irritation  is 
the  lack  of  protection  to  the  organ  in  our  extreme  methods  of  cavity 
preparation  in  filling  vital  teeth,  frequently  resulting  in  the  metallic 
inlay  or  filling  being  placed  in  too  close  proximity  to  the  pulp.  It 
is  not  my  intention  to  decry  the  principles  involved  in  Operative 
Dentistry;  but  my  experience  has  taught  me  that  in  filling  proximo- 
occlusial  cavities  in  molar  and  bicuspid  teeth,  -especially  with  inlays, 
with  the  opportunity  afforded  for  occlusal  anchorage,  it  is  not  neces- 
sary to  approximate  the  pulp  as  closely  as  is  advocated  by  some 
teachers  on  the  ground  of  principle.  This  word  "principle"  is 
a  broad  term,  and  we  should  remember  that  there  are  principles 
involved  in  the  treatment  and  protection  of  the  dental  pulp  as  well 
as  in  the  retaining  of  a  filling  or  inlay  in  the  tooth.  I  have  long  since 
stopped  trying  to  make  myself  and  my  patients  believe  that  teeth, 
the  pulps  of  which  are  thus  continuously  irritated  by  thermal  changes, 
will  soon  be  cared  for  by  Nature,  when  no  further  trouble  will  be 
experienced.  On  the  contrary,  I  know  that  while  Nature  is  a  kind 
mother,  sometimes  I  think  so  kind  that  we  are  inclined  to  take  undue 
advantage  of  her,  yet  in  the  majority  of  cases,  both  constructive 
and  destructive  diseases  result  which  subsequently  necessitate  the 
removal  of  the  pulp. 

Many  pulps  have  been  irritated  and  frequently  passive  hyperemia 
or  inflammation  has  been  produced  by  the  injudicious  use  of  gutta- 
percha for  sealing-in  dressings  or  for  separating  purposes  when 
proximal  cavities  existed.  Unless  due  care  is  taken  in  the  use  of 
this  material,  even  when  the  cavities  are  not  deep  and  when  no 
active  hyperemia  is  present,  infectious  material  or  the  medicine 
is  liable  to  be  forced  through  the  dentin  and  into  the  pulp,  causing 
the  diseases  above  mentioned  and  jeopardizing  the  life  of  the  organ. 
Cement  had  better  be  used  for  temporary  sealing  purposes,  and  before- 
separating  carious  teeth  with  gutta-percha  the  cavities  should  be 
cleansed  of  debris,  and  the  dentin  sterilized.  The  cause  of  pulp 
trouble  following  the  filling  of  a  vital  tooth  can  often  be  traced  to  the 
lack  of  sterilization  of  the  dentin  before  the  filling  was  inserted. 
Let  it  be  remembered  that  preventive  therapeutics  is  the  watch-word 
of  the  hour. 

It  should  be  understood',  then,  that  the  dental  pulp  is  a  delicate 
and  susceptible  organ,  responding  to  the  slightest  irritation,  it 
matters   not  whether   the   irritant   be   of   a   thermal,   mechanical, 


TREATMENT    OF   DISEASES    OF    THE    DENTAL   PULP  3OI 

chemical,  or  electrical  nature.  Inasmuch  as  any  one  of  these 
various  classes  of  irritants  may  cause  hyperemia  of  the  pulp,  and 
this  disease,  if  continuous  and  progressive,  may  result  in  more 
serious  pathologic  conditions,  I  will  now  direct  your  attention  to 
the  pathology  of  this  organ,  considering  the  etiology,  diagnosis  and 
treatment  of  (i)  such  Constructive  and  (2)  Destructive  Diseases 
as  are  commonly  found  in  the  general  practice  of  dentistry. 


CONSTRUCTIVE  DISEASES 

SECONDARY  DENTIN 

The  deposition  of  what  is  known  as  secondary  dentin  frequently 
occurs  in  the  pulp-chambers  of  teeth  as  the  result  of  sHght  but  con- 
tinued irritation  of  the  pulpal  organ,  after  ithias  enjoyed  a  physiologic 
period  of  rest  from  dentin  formation.  This  particular  calcific 
deposit  is  always  attached  to  the  dentin,  immediately  under  the  site 
of  irritation;  and,  if  produced  in  a  limited  amount  only,  affords  a 
natural  protection  to  the  pulp.  The  causes  of  secondary  dentin  are 
many  and  varied.  The  stimulus  may  result  from  such  external 
irritation  as  follows: 

1.  Exposed  Cementum. 

2.  Abraded  or  Eroded  Surfaces. 

3.  Cavities  of  Decay. 

4.  Metallic  Fillings. 

5.  Gold  or  Porcelain  Jacket  Crowns  upon  ground-down  vital 
teeth,  etc. 

It  is  possible  and  oftentimes  advantageous  to  so  treat,  stimulate 
and  yet  protect  the  pulp  in  cases  of  deep-seated  cavities  that  a 
layer  of  secondary  dentin  will  be  deposited.  I  shall  refer  to  this 
again  in  connection  with  the  treatment  of  active  hyperemia  of  the 
pulp. 

In  those  cases  where  the  stimulus  continues  over  a  period  of 
years,  we  are  quite  likely  to  find  the  pulp-chamber  and  root-canals 
filled  with  secondary  dentin.  The  diagnosis  and  treatment  of  this 
condition  is  unimportant  unless  untoward  symptoms  arise  indicat- 
ing an  acute  apical  pericemental  involvement  or  neuralgia,  in  which 
case  the  pulp  should  be  removed.  The  radiograph  here  is  an  in- 
valuable aid  in  arriving  at  a  correct  diagnosis.  The  removal  of  the 
pulp  in  these  cases  is  often  a  difficult  problem,  for  neither  cocain 
hydrochlorid  nor  arsenic  trioxid  will  affect  pulps  thus  diseased  in 
the  usual  way.  It  is  frequently  necessary  to  resort  to  conductive 
or  interosseous  anesthesia  or  to  the  administration  of  nitrous  oxid 
and  oxygen  in  order  to  remove  these  pulps  without  pain.  Many 
an  obscure  case  of  neuralgia  has  this  condition  as  its  greatest  etio- 
logical factor.     This  will  be  referred  to  again  in  detail  under  the 

302 


CONSTRUCTIVE   DISEASES 


303 


Diagnosis  and  Treatment  of  Neuralgia.  The  author  has  had  many 
cases  in  his  practice  where  the  canals  were  nearly  and  in  some 
instances  completely  obliterated  without  any  untoward  symptoms 
being  manifested.  Such  a  case  is  illustrated  in  Fig.  6.  In  this  case 
I  desired  to  insert  a  bridge.  On  opening  into  the  third  molar 
and  second  bicuspid,  which  teeth  were  to  be  used  for  the  abut- 
ments, we  were  unable  to  find  any  canals  in  the  bicuspid  and 
only  a  small  lingual  canal  in  the  molar.     The  radiograph  confirmed 


Fig.  6. 

the  clinical  findings.  The  patient  gave  a  history  of  having  had  an 
operation  for  abscess  of  the  frontal  sinus  and  both  antrums  about 
ten  years  previous.  The  bridge  was  inserted  in  January,  1909,  and 
has  given  no  trouble  since. 

PULP  NODULES  ■ 

Pulp  nodules  are  calcific  bodies  of  varying  shapes  and  sizes, 
supposedly  the  result  of  secretion,  and  occurring  within  the  pulp, 
rarely,  if  ever,  being  attached  to  the  dentin.  They  are  found 
more  generally  in  middle-aged  or  elderly  patients  whose  teeth  have 
been  subjected  to  that  continued  irritation  the  source  of  which  was 
mentioned,  as  an  etiologic  factor  in  the  formation  of  secondary 
dentin.  Black,  however,  observes  that  pulp  nodules  may,  and  fre- 
quently do,  form  in  other  teeth  of  the  same  denture  which  are  not 
directly  involved  in  the  irritation;  and  that  irritation  of  the  pulp 
of  one  tooth  very  frequently  causes  a  general  hyperesthesia  of  the 
pulps  of  all  the  teeth  in  that  mouth ;  especially  is  this  true  of  that 
type  of  individual  classed  as  neuralgic. 

The  diagnosis  of  pulp  nodules  is  not  always  a  simple  matter. 
The  symptoms  are  of  the  subjective  variety,  and  the  radiograph 
does  not  always  confirm  the  suspicion.  Moorehead,  Raper,  and 
others  have  reported  cases  where  pulp  nodules  are  distinctly  shown 


304 


PRACTICAL   DENTAL    THERAPEUTICS 


in  the  picture.  The  author  has  recently  observed  several  such 
cases.  On  opening  into  the  tooth  the  nodule  was  found  to  be  present. 
In  Fig.  7  is  shown  the  best  specimen  of  a  pulp  nodule  that  I 
have  ever  seen.  The  tooth  is  a  lower  third  molar  and  was  extracted 
because  it  was  causing  more  or  less  trouble.  There  is  but  slight 
mechanical  abrasion  and  no  other  known  cause  for  the  pathologic 


Fig.  7. 

condition.  Fig.  8  shows  a  pulp  nodule  nearly  one-quarter  of  an 
inch  long  which  fits  the  canal  as  perfectly  as  a  pea  fits  the  pod.  The 
tooth  for  years  had  carried  an  ill-adjusted  gold  shell  crown,  which 
had  been  placed  without  devitahzation  and  the  proper  trimming  of 
the  root.  In  the  illustration  also  are  shown  several  nodules  of  vary- 
ing shapes  and  sizes,  such  as  are  commonly  found  in  practice.     The 


'ft.'    tei* 


Fig.  8. 


following  five  illustrations  are  from  Dr.  Howard  R.  Raper,  of 
Indianapolis,  a  dental  radiographer,  whose  opinion  I  value  highly. 
His  description  follows: 

"Fig.  9.  The  upper  arrow  points  to  a  pulp  nodule  in  a  lower 
first  molar.  The  radiograph  is  by  Pfahler,  of  Philadelphia,  and  I 
have  no  rehable  history  of  the  case.  The  radiograph  would  lead 
me  to  believe  that  the  pulp-chamber  has  been  opened  up  and  much 
of  the  dentin  cut  away  from  about  the  nodule;  hence  the  latter  can 


Fig.  9. 


Fig.  10. 


Fig.  II. 


Fig.  12. 


Fig.  13 


CONSTRUCTIVE   DISEASES  $0$ 

be  seen  much  more  clearly  than  any  other  I  have  ever  seen  in  a 
radiograph. 

"Fig.  lo.  In  this  case  the  upper  third  molar  is  missing.  A  pulp 
nodule  is  seen  in  the  pulp-chamber  of  the  upper  second  molar.  This 
molar  has  not  been  opened  as  yet,  nor  will  I  advise  the  operator  to 
open  the  tooth  until  I  have  made  another  radiograph  to  verify  the 
findings  in  the 'first  one.  The  case  is  one  of  neuralgia  with  an  obscure 
etiology  and  a  history  of  pulp  nodules  having  been  found  in  other 
teeth.  I  am,  therefore,  strongly  of  the  opinion  that  the  shadow  seen 
in  the  radiograph  is  a  pulp  nodule.  The  radiograph  shows  also  a 
faulty  canal  filling  in  the  lower  molar — a  condition  capable  of  causing 
pain.  The  treatment  of  the  lower  molar,  however,  has  failed  to 
give  rehef ,  which  leads  me  to  believe  that  the  neuralgia  is  due  to  the 
pulp  nodule. 

"Fig.  II.  This  is  a  case  from  the  practice  of  Dr.  M.  L.  Rhein, 
of  New  York)  and  shows  a  pulp  nodule  in  an  upper  lateral  incisor 
with  an  abscess  at  the  end  of  the  incompletely  formed  root.  The 
diagnosis  was  verified  by  removing  the  nodule. 

"Fig.  12  shows  a  shadow  in  the  lower  first  molar  which  might 
be  mistaken  for  a  pulp  nodule.  The  shadow  is  a  small  amalgam 
filHng  on  the  buccal  near  the  gingival  line. 

"Fig.  13.  These  negatives  show  nodules  in  all  four  lower  in- 
cisors. The  nodules  in  the  central  incisors  extend  practically  from 
chamber  to  apex.  The  teeth  have  been  extracted  and  dissected  and 
the  diagnosis  verified.  Though  these  nodules  can  be  seen  in  the 
negatives  it  is  improbable  that  lantern  slide  cuts  made  from  the 
negatives  would  show  them. 

"There  is  no  longer  any  doubt  as  to  whether  or  not  pulp  nodules 
can  be  radiographed.  They  can  be,  but  it  is  difficult,  I  would 
never  make  a  diagnosis  from  one  radiograph.  I  would  make  at 
least  two." 

The  treatment  of  teeth  containing  pulp  nodules  which  are  causing 
neuralgia  or  other  disturbances  is  practically  the  same  as  that  of 
secondary  dentin,  which  involves  the  removal  of  the  pulp,  and  will 
be  considered  later. 


DESTRUCTIVE  DISEASES 

It  is  often  a  difficult  problem  for  the  conscientious  operator  to 
decide  upon  a  method  of  procedure  that  will  best  conserve  the  interest 
of  the  patient.  Especially  is  this  true  when  we  are  trying  to  deter- 
mine whether  a  diseased  pulp  should  be  saved  or  whether  it  would  be 
best  for  all  concerned  to  destroy  and  remove  it.  It  is  so  easy  in 
most  cases  to  anesthetize  or  devitalize  the  pulp  that  many  dentists 
resort  to  this  method  of  treatment  in  nearly  all  diseases  of  the  organ. 
When  we  consider  the  fine  and  tortuous  canals  which  we  so  frequently 
encounter  and  the  difficulty,  both  of  removing  the  dead  tissue  from 
such  canals  and  of  thoroughly  filling  them  subsequently,  it  is  a  ques- 
tion whether  or  not  the  best  interest  of  the  patient  is  conserved  by 
adopting  this  method  as  the  general  practice. 

While  it  is  true,  generally  speaking,  that  pulps  which  are  diseased 
beyond  the  condition  of  active  hyperemia  should  be  removed,  it  is 
also  true  that  this  organ  has  been  destroyed  far  too  ruthlessly  in  the 
past.  The  work  of  Rosenow,  the  observations  of  Hunter,  Murphy, 
Billings,  the  Mayos,  Crile,  and  others  of  the  medical  profession, 
and  the  investigations  of  Grieves,  Rhein,  Gilmer,  Price,  Logan, 
Moorehead,  HartzeU,  and  others  of  our  own  profession,  along  the 
line  of  periapical  infections  and  the  systemic  results,  should  teach  us 
to  conserve  the  dental  pulp  in  every  case  where  it  is  practicable  and 
consistent  with  good  dentistry.  Thousands  upon  thousands  of  nor- 
mal pulps  have  been  sacrificed  for  no  other  reason  than  that  the 
dentin  of  the  tooth  was  h3rpersensitive.  When  we  think  of  the  diffi- 
culty— not  to  mention  the  carelessness — under  which  these  pulps 
are  often  removed,  and  of  the  frequent  periapical  infections  resulting 
therefrom,  we  behold  a  sad  spectacle,  indeed! 

I  have  never  heretofore,  nor  do  I  intend  now,  to  plead  for  the 
life  of  the  pulp  when  the  reading  of  the  clinical  symptoms  clearly 
indicates  its  removal;  but  I  do  mean  to  say  that  in  all  cases  an  effort 
should  be  made  to  determine  as  nearly  as  possible  the  exact  patho- 
logic condition,  and  our  decision  should  be  based  upon  these  findings. 
From  the  viewpoint  of  the  diagnostician  there  are  few  subjects  of 
greater  importance  than  those  of  hyperemia  and  inflammation  of 

the  dental  pulp. 

306 


DESTRUCTIVE   DISEASES  307 

Diagnosis  of  Active  and  Passive  Hyperemia,  and  True  Pulpitis. — 

In  the  pulp  tissue,  as  in  all  living  tissues  of  the  body,  we  may  have 
two  kinds  of  hyperemia — active,  or  arterial,  and  passive,  or  venous. 
The  former  is  defined  as  an  excessive  amount  of  blood  in  the  arteries 
and  the  latter  as  an  excessive  amount  of  blood  in  the  veins.  Active 
hyperemia  is  due  to  a  determination  of  blood  to  a  given  part  as  the 
result  of  reaction  to  an  irritant,  and  as  long  as  it  remains  without  an 
excessive  immigration  of  the  white  blood  corpuscles,  it  is  active,  or 
arterial  hyperemia.  The  cause  of  passive  hyperemia  is  different. 
Here  the  blood  may  be  held  back  by  some  obstruction  in  the  veins 
which  prevents  the  return  of  blood  to  the  heart.  Inglis  says:  "The 
backing  up  of  the  blood  following  venous  obstruction  produces  ten- 
sion upon  the  vessels,  followed  by  diapedesis  of  red  corpuscles  and 
exudation  of  watery  fluid — the  condition  of  edema.  In  inflamma- 
tion arterial  h3^eremia  appears  as  the  first  stage,  followed  by  a  collec- 
tion of  leucocytes  along  the  walls  of  the  small  veins,  and  the  immigra- 
tion of  some  into  the  perivascular  tissue.  As  this  eventually  leads  to 
stoppage  of  the  blood  current,  and  even  to  stasis,  the  condition  is 
essentially  a  venous  hyperemia.  Accompanying  the  immigration  of 
leucocytes  is  an  exudation  of  lymph,  highly  coagulable  in  character, 
which  distends  the  lymph  spaces  in  the  tissue  and  produces  the 
characteristic  swelling." 

The  thing  of  special  interest  here  is  that  in  inflammation  or 
even  in  venous  hyperemia  certain  blood  elements  escape  through 
the  temporarily  dilated  vessels  into  the  perivascular  tissue,  which 
becomes  coagulated,  and  when  the  tissue  involved  is  the  dental  pulp, 
which,  as  we  have  learned,  is  without  lymphatics,  this  coagulation 
of  the  fluid  elements  of  the  blood  means  death.  The  procedure  of 
many  practitioners  when  an  aching  tooth  presents  involving  the 
pulp  is  simply  to  find  out  whether  the  latter  is  dead  or  alive.  If  alive, 
cocain  hydrochlorid  or  arsenic  trioxid  is  generally  applied,  or  else 
the  tooth  is  treated  tentatively  by  placing  cotton  dipped  in  oil  of 
cloves  or  some  other  soothing  remedy  in  the  cavity,  and  the  patient 
is  dismissed  without  making  any  effort  to  ascertain  the  condition  of 
the  pulp — whether  it  is  in  the  stage  of  active  hyperemia  or  passive 
hyperemia  or  true  inflammation.  If,  on  the  other  hand,  the  pulp 
is  found  to  be  dead,  the  tooth  is  too  frequently  treated  by  opening 
up  the  pulp  chamber  and  placing  therein  a  pledget  of  cotton  dipped 
into  the  most  convenient  remedy  at  hand,  leaving  the  cavity  un- 
sealed for  fear  of  causing  septic  pericementitis  or  an  acute  alveolar 
abscess,  and  making  no  further  effort  to  ascertain  whether  the  pulp 
has  been  infected  by  pyogenic  microorganisms,  producing  pus  on 


3o8  PRACTICAL   DENTAL   THEEAPEUTICS 

the  exposed  surface  or,  as  sometimes  occurs,  within  the  substance  of 
the  tissue,  or  whether  the  germs  inaugurating  the  changes  are  of 
the  saprophitic  variety  causing  pulp  decomposition  with  gaseous 
end-products.  It  is  highly  essential,  therefore,  when  a  patient 
presents  with  an  aching  tooth,  that  we  take  the  time  and  trouble  to 
determine  not  only  whether  we  have  a  Hve  or  a  dead  pulp  with  which 
to  contend,  but,  if  the  pulp  is  aHve,  whether  the  condition  is  one  of 
active  hyperemia  only  or  passive  hyperemia  or  inflammation;  or,  if 
the  pulp  is  dead,  whether  the  condition  is  a  so-called  septic  pulp  with 
pus  formation  (pulpal  abscess)  or  one  of  true  gangrene  with  gase- 
ous end-products.  To  confirm  our  diagnosis  the  tooth  should  be  iso- 
lated and  kept  dry,  preferably  with  the  rubber  dam,  and  a  careful 
examination  made.  On  no  other  basis  can  rational  therapeutics 
be  practised. 

Differential  Diagnosis. — It  is  generally  a  simple  matter,  by 
asking  a  few  questions  and  observing  conditions,  to  differentiate 
between  the  pathologic  conditions  of  a  vital  pulp  sufficiently  to 
determine  whether  the  pulp  had  better  be  saved  or  destroyed.  In 
acute  active  hyperemia  the  pain  occurs  only  when  the  irritant  is 
applied,  and  subsides  almost  momentarily  without  treatment. 
Logan  states  that  ''active  hyperemia  exists  in  a  pulp  when  the  pain 
begins  with  a  known  irritation,  lasting  only  a  few  moments,  or  min- 
utes at  the  most,  and  subsiding  without  treatment  and  not  starting 
again  until  the  application  of  another  known  irritant  is  made." 

Treatment  of  Active  Hyperemia. — The  treatment  of  this  con- 
dition consists  in  pr£)tecting  the  tooth  from  the  irritant  which  caused 
the  disease.  If  a  cavity  exists  which  is  causing  the  trouble  an  ano- 
dyne remedy  is  indicated.  One  treatment  with  phenol  compound,  or 
other  remedies  possessing  similar  properties,  should  cure  a  case  of 
active  hyperemia  due  to  caries  of  the  tooth.  At  the  second  sitting, 
if  the  case  has  a  favorable  history,  the  rubber  dam  should  be  ad- 
justed and  the  dressing  and  carious  dentin  removed,  after  which  a 
base  of  cement  may  be  inserted,  the  cavity  prepared,  and  the  tooth 
filled.  In  those  cases  where  the  cavity  is  deep  and  encroaches  upon 
the  pulp,  and  where  the  removal  of  the  softened  dentin  practically 
or  actually  exposes  the  organ,  it  is  necessary,  in  order  to  save  the 
pulp,  to  cap  and  protect  it.  This  brings  us  to  a  consideration  of 
pulp  capping. 

Factors  to  be  Considered  in  Pulp  Capping. — There  are  several 
important  factors  to  be  considered,  and  upon  these  will  largely  de- 
pend the  success  or  failure  following  an  attempt  to  save  the  pulp 
after  it  has  actually  been  exposed.     In  an  accidental  exposure  in  the 


DESTRUCTIVE   DISEASES  309 

preparation  of  a  cavity,  the  chances  of  saving  the  pulp,  provided  the 
injury  has  not  been  too  great,  are  far  more  favorable  than  if  the  pulp 
had  been  exposed  by  the  necessary  removal  of  the  carious  dentin. 
Our  success  will  also  depend  in  no  small  degree  upon  the  condition 
of  the  pulp  as  well  as  upon  the  general  condition  of  the  mouth  of  the 
patient  in  which  the  exposure  occurs.  In  cases  of  hyperemia  of  the 
pulp  an  effort  should  be  made  to  determine  whether  it  is  active  or 
passive  hyperemia,  and  where  pulpitis  is  present  our  prognosis  will 
be  governed  largely  by  ascertaining  whether  the  pulpitis  is  partial 
or  complete,  or  of  the  nonseptic  or  septic  variety.  If  there  is  con- 
gestion or  any  evidence  of  degeneration  of  the  structural  compo- 
nents of  the  pulpal  organ  itself,  it  would  be  futile  to  attempt  to  cap  it. 
Logan  is  of  the  opinion  that  most  pulps,  the  exposure  of  which  has 
been  brought  about  by  caries,  have  undergone  sufficient  inflammatory 
changes  to  cause  their  ultimate  death,  even  when  carefully  capped. 
Any  attempt  to  permanently  save  an  exposed  pulp  in  the  mouth  of  a 
patient  who  is  suffering  from  some  systemic  derangements  inter- 
fering with  the  general  circulation,  thus  lessening  vital  resistance, 
would  doubtless  result  in  failure  also,  for  in  such  cases  the  pulp  would 
fail  to  receive  from  the  blood  supply  the  necessary  elements  for  the 
restoration  of  its  functional  activity.  The  general  condition  of  the 
mouth  itself  and  the  care  it  receives  daily  from  the  patient,  are 
essential  factors  to  be  taken  into  consideration  before  proceeding  to 
cap  a  pulp;  for  Hopkins,  of  Boston,  in  a  carefully  conducted  series 
of  experiments  to  ascertain  the  difference  in  virulency  of  certain 
pathogenic  bacteria  in  different  mouths,  and  in  the  same  mouth  under 
differing  conditions,  proved  that  not  only  did  the  germs  proliferate 
more  rapidly  in  neglected  and  uncared-for  mouths,  but  their  patho- 
genic properties  were  greatly  increased. 

Exceptional  Cases  of  Exposure. — There  is  one  class  of  cases  of 
pulp  exposure  which  frequently  present  in  a  busy  practice  and  in 
which  it  is  our  plain  duty  to  make  the  attempt  to  restore  the  organ 
to  its  normal  function,  even  though  the  conditions  for  doing  so  are 
not  altogether  favorable.  I  mean  here  those  cases  in  the  mouths  of 
young  patients  where  the  pulp  is  exposed  from  decay  and  the  roots  of 
the  tooth  have  not  been  fully  developed.  Every  effort  should  be 
made  to  cap  such  a  pulp,  provided  the  cUnical  symptoms  are  at  all 
favorable,  and  thereby  save  it,  if  for  only  a  year  or  two;  for  experi- 
ence has  demonstrated  that  to  remove  the  pulp  and  properly  close 
the  large  openings  in  the  ends  of  the  roots  is,  at  best,  a  difficult  pro- 
cedure; that  a  tooth  in  this  condition,  thus  treated,  is  usually  a  source 
of  infection  and  its  usefulness  generally  of  short  duration. 


3IO  PRACTICAL   DENTAL   THERAPEUTICS 

In  another  class  of  cases  the  author  also  believes  that  we  are  justi- 
fied in  capping  the  pulp.  For  instance,  in  those  cases  of  exposure 
where  for  certain  reasons  it  is  desirable  to  save^  the  tooth,  and  on 
which  it  would  be  difficult  to  adjust  the  rubber  dam,  aseptically 
remove  the  pulp,  and  thoroughly  fill  the  canals.  I  wish  to  state 
here,  however,  that  I  do  not  mean  to  infer  that  a  pulp  should  be 
capped  in  an  anterior  tooth,  because  of  the  liability  of  the  tooth- 
structure  discoloring  after  the  pulp  has  been  removed.  This  phase 
of  the  subject  will  be  referred  to  in  detail  subsequently  under  the 
Preservation  of  the  Color  of  the  Tooth  in  Pulp  Removal. 

From  the  foregoing,  then,  it  should  readily  be  understood  that  no 
set  of  rules  can  be  given,  the  application  of  which  will  surely  lead  to 
success.  Every  case  must  be  studied  and  treated  according  to  the 
pathologic  conditions  found  and  the  operator's  best  judgment,  after 
having  taken  into  consideration  all  these  various  factors. 

Therapeutics  of  Pulp  Capping. — There  are  several  methods  of 
capping  the  pulp,  each  differing  in  minor  details,  such  as  the  use  of 
various  cements,  gutta-percha,  concave  metallic  disks,  etc.,  etc. 
The  reader's  attention  will  first  be  directed  to  the  general  precautions 
to  be  taken  in  following  the  different  methods  of  capping;  after  which 
one  method  will  be  described  in  detail  which  has  proved  successful  in 
the  author's  practice.  By  this  I  do  not  mean  to  convey  the  idea  that 
all  pulps  which  I  have  attempted  to  save  have  been  rehabiHtated  to 
their  functional  activity — many  have  not;  however,  a  sufficient 
number  of  those  thus  treated  have  remained  quiet,  and  proved  years 
later  to  be  vital,  to  justify  making  the  attempt  where  the  case 
demands  it. 

Precautions. — The  precautions  to  be  observed  in  following  any 
method  are: 

1.  By  the  use  of  an  anodyne,  the  hyperemic  pulp,  if  in  this  con- 
dition, must  he  restored  to  normal  before  the  final  capping. 

2.  The  dentin  overlying  the  pulp  must  he  thoroughly  sterilized. 
It  should  be  noted  here  that  the  usual  perfunctory  method  of  steriliz- 
ing the  dentin  by  simply  applying  a  germicidal  solution  to  the  cavity 
for  a  few  moments  does  not  sterilize  to  the  degree  necessary  for  suc- 
cessful results.  The  lack  of  thorough  sterilization  has,  without 
doubt,  been  the  chief  cause  of  failure  in  many  instances.  The 
accuracy  of  this  statement  will  be  seen  when  we  remember  that  our 
greatest  success  has  followed  the  capping  of  pulps  which  have  been 
accidentally  exposed  with  a  bur  or  instrument  in  preparing  a  cavity, 
although,  in  most  cases,  greater  mechanical  injury  had  been  caused 
than  when  the  exposure  was  due  to  caries  or  the  removal  of  carious, 
dentin. 


DESTRUCTIVE   DISEASES  31I 

3.  Pressure  in  applying  the  material  for  capping,  or  the  cement 
which  covers  the  capping,  must  he  avoided. 

Technic. — ^After  breaking  down  all  overhanging  edges  of  enamel 
and  removing  as  much  of  the  debris  and  softened  dentin  as  can  be 
done  without  pain  or  injury  to  the  pulp,  the  cavity  should  be  flooded 
with  a  mild,  nonirritating,  antiseptic  solution,  previously  heated  to 
the  temperature  of  the  body.  For  this  purpose  the  author  suggests 
the  use  of  one  of  the  following  remedies: 

I^ — Phenolis,  fSss  (2.0  mils) 

\  Aquae  menthae  piperitse,  fSvj  (180.0  mils) — M. 

Sig. — Use  wherever  a  mild,  nonirritating  antiseptic  solution 
is  indicated. 

I^ — Alcoholis,  3j  (4-0  mils) 

Aquae  cinnamomi,  f§vj  (180.0  mil) — M. 
Sig. — Use  as  a  spray. 

These  solutions  can  be  used  as  a  spray  or  with  a  water  syringe 
before  appl3dng  the  rubber  dam,  thus  adding  comfort  and  cleanliness 
to  the  operation.  The  excess  can  now  be  absorbed  from  the  cavity 
with  cotton  and  the  dam  adjusted.  By  using  some  obtunding  rem- 
edy and  a  sharp  spoon  excavator,  or  oftentimes  a  large  round  bur 
in  the  engine,  the  carious  dentin  can  be  removed.  If,  however,  the 
thorough  removal  of  all  the  discolored  dentin  would  make  a  large 
exposure,  it  is  best  to  leave  the  layer  overling  the  pulp  and  depend 
upon  the  sterilizing  agent,  rather  than  to  jeopardize  the  life  of  this 
organ  by  the  injury  thus  produced.  The  delicate  pulp  tissue  will 
not  tolerate  much  abuse  and  remain  quiet,  therefore,  if  it  is  injured  to 
any  great  extent  it  had  better  be  removed  at  once.  The  dentin  can 
now  be  steriUzed  by  sealing  in  the  cavity,  for  a  few  days,  the  following 
remedy  which  is  not  only  germicidal  in  action,  but  possesses  marked 
anodyne  properties  as  well: 

I^ — Mentholis,  gr.  xx  (1.3  Gm.) 

Camphorae  gr.  xl  (2.69  Gm.) 

Phenolis,  (U.S.P.)  f  3iij  (12.0  mils)— M. 
Sig. — Use  as  directed. 

For  convenience  this  remedy  has  been  called  phenol  compound. 

It  is  best  to  seal  with  a  veneer  of  quick-setting  cement,  previously 
filUng  most  of  the  cavity  with  cotton,  thereby  avoiding  pressure  and 
facilitating  the  subsequent  removal  of  the  dressing.  By  this  means 
the  dentin  can  be  thoroughly  sterilized,  and  the  pulp,  if  at  all  hyper- 
emic,  as  it  is  likely  to  be,  will  return  to  its  normal  condition. 

Thymol  has  a  peculiar  but  favorable  action  on  animal  tissue 
and  for  this  reason  it  was  formerly  incorporated  in  the  above  pre- 


312  PRACTICAL   DENTAL   THERAPEUTICS 

scription.  The  later  formula  for  phenol  compound  contains  cam- 
phor instead  of  thymol,  which  enhances  the  anod3aie  property  of 
the  remedy.  At  the  next  sitting,  the  case  giving  a  favorable  history 
for  the  interim,  the  dam  should  always  be  applied,- the  teeth  included 
sterilized,  and  the  previous  dressing  carefully  removed,  when  the 
exposure  and  dentin  immediately  over  the  pulp  can  be  gently  covered 
with  a  thin  paste  made  by  mixing  thymolized  calcium  phosphate  with 
oil  of  cloves  or  eugenol.  A  prescription  for  the  thymolized  calci'am 
phosphate  follows: 

I^ — Thymolis,  gr.  x  (0.6  Gm.) 

Calcii  Phosp.  ppt.  (purificata),    oj  (32.0  Gm.) — M. 
Sig. — Use  as  the  powder  for  making  paste. 

The  paste  should  be  placed  on  one  side  of  the  cavity  and  gently 
coaxed  over  the  exposure  in  such  a  manner  as  to  exclude  the  air.  I 
desire  to  emphasize  the  importance  of  covering  the  entire  dentin  im- 
mediately over  the  pulp,  as  well  as  the  exposure,  with  this  antiseptic 
and  non-irritating  paste.  By  this  means  we  prevent  the  phosphoric 
acid  of  the  cement,  used  to  cover  the  paste  and  to  temporarily  fill  the 
cavity,  from  irritating  the  pulp.  It  should  be  understood  that  this 
paste  is  only  intended  as  a  nonirritating,  antiseptic  covering  for  the 
pulp.  1 1  does  not  set.  To  bring  about  "setting,"  it  would  be  neces- 
sary to  use  a  substance  for  the  powder  and  an  acid  for  the  liquid  which 
react  upon  each  other.  This  would  cause  irritation,  thus  defeating 
our  object.  It  is  best,  as  intimated  here,  to  fill  the  entire  cavity  with 
cement  and  wait  for  a  few  months  or  perhaps  a  year  before  inserting 
the  permanent  filling  or  inlay;  and  even  then  we  should  be  certain 
that  the  vitality  of  the  pulp  has  been  retained,  for  frequently  exposed 
pulps,  under  the  most  careful  treatment,  gradually  die  without  any 
objective  symptoms.  The  fact  that  the  tooth  has  given  no  trouble 
should  not  be  taken  as  evidence  that  the  pulp  is  alive,  for  the  reverse 
is  too  often  true — the  drugs  in  the  capping  material  keeping  the  tis- 
sue, though  dead,  from  undergoing  decomposition  for  months  and 
sometimes  for  years. 

Every  advantage  should  be  taken  to  prevent  all  possible  means  of 
subsequent  irritation  to  the  pulp.  For  this  reason  the  author  uses 
precipitated  calcium  phosphate  instead  of  calcined  zinc  oxid,  which 
latter  substance  is  recommended  by  many  writers.  The  powder 
(largely  zinc  oxid)  which  comes  with  a  package  of  cement  is  supposed 
to  be  chemically  pure.  Those  who  are  familiar  with  the  science  of 
chemistry,  however,  know  that  arsenic  is  found  associated  in  Nature 
with  many  of  the  metals,  among  which  is  zinc;  and,  while  it  can  be 


DESTRUCTIVE   DISEASES  313 

done,  it  is  difl&cult  to  obtain  these  metals  or  their  oxids  free  from 
arsenic.  It  is  well  in  those  cases  where  the  pulp  is  not  quite  exposed, 
to  add  a  small  amount  of  either  aristol  or  europhen  to  the  paste. 
These  are  iodin  compounds  and  are  used  as  substitutes  for  iodoform. 
They  act  as  a  mild  stimulant  to  the  pulp,  thus  causing  secondary 
dentin  to  be  deposited,  when  we  have  Nature's  protection.  Both 
are  tasteless,  practically  without  odor,  and  insoluble  in  water,  but 
soluble  in  the  oil  used  as  the  vehicle  for  the  paste;  therefore,  only  a 
small  amount  should  be  added,  for  it  is  possible  to  overstimulate  the 
pulp,  with  the  result  of  bringing  about  a  pathologic  rather  than  a 
physiologic  condition. 

I  desire  to  emphasize  the  importance  of  studying  carefully  the 
conditions  as  found  in  each  case;  and  to  say  that  the  opportunity 
here  for  exercising  good  judgment  is  very  great,  and  that  there  is  a 
satisfaction  in  realizing,  whether  we  succeed  or  fail  in  our  effort  to 
save  the  pulp,  that  we  did  our  duty  as  we  saw  it. 

Treatment  of  Passive  Hyperemia  and  True  Liflammation.— As 
far  as  therapeutics  is  concerned,  it  is  of  little  importance  to  know 
whether  the  pathologic  condition  of  the  pulp  is  passive  hyperemia 
or  true  inflammation.  In  either  case  we  have  transudation  of  the 
fluid  elements  of  the  blood  and  diapedesis  of  the  red  corpuscles 
occurring,  and  this  means  death  ultimately.  In  passive  hyperemia 
the  pain  is  more  constant  than  in  active  hyperemia,  and  may  start 
without  the  application  of  a  known  irritant.  In  inflammation  the 
pain  is  continuous  and  of  a  boring  character,  or  it  may  be  lancinat- 
ing, and  is  frequently  described  by  the  patient  as  a  ''jumping  tooth- 
ache." When  the  reading  of  the  symptoms  indicates  either  of  these 
conditions,  our  therapeutics  differs  from  that  prescribed  for  active 
hyperemia,  for  here,  as  has  been  previously  stated,  the  pulp  must  be 
destroyed. 


THE  REMOVAL  OF  VITAL  PULPS  AND  SUBSEQUENT 

TREATMENT 

GENERAL  CONSIDERATIONS 

Embryologists  claim  that  when  the  roots  of  a  tooth  are  fully 
developed,  the  pulp  has  no  further  function  to  perform.  If  this 
theory  can  be  accepted  as  correct,  and  I  think  that  it  is  quite  well 
established,  it  would  appear  from  the  large  percentage  of  failures 
following  the  most  careful  methods  of  pulp  capping  that  the  safest 
and,  therefore,  the  best  practice  would  be  to  destroy  the  vitality  and 
remove  the  pulp  in  all  cases  where  this  deHcate  and  susceptible 
tissue  has  been  previously  irritated  for  any  great  length  of  time,  un- 
less, as  explained  under  Exceptional  Cases  of  Exposure  (p.  309), 
there  is  some  special  reason  for  attempting  to  restore  the  organ 
to  its  functional  activity.  From  sad  past  experience  the  author  has 
been  led  to  adopt  this  general  practice.  By  this  I  do  not  wish  to 
convey  the  idea  that  it  is  advisable  or  necessary  to  injudiciously  or 
ruthlessly  destroy  pulps,  for  this  is  not  the  case.  As  has  been 
previously  emphasized,  it  is  the  plain  duty  of  every  dental  practi- 
tioner to  save  the  pulps  of  teeth,  if  it  can  be  done  with  any  reasonable 
degree  of  success.  There  are  many  conditions,  some  of  which  are 
pathologic  and  others  are  not,  which  necessitate  the  removal  of  the 
pulp,  such  as: 

1.  Dental  Caries. — In  those  cases  where  dental  caries  has  en- 
croached upon  the  pulp  to  the  extent  of  producing  passive  hyperemia 
or  true  inflammation,  especially  the  latter  disease.  The  pulp  here 
oftentimes  has  been  invaded  by  pathologic  bacteria,  and  frequently 
the  tissue  has  absorbed  poisonous  ptomains  or  toxins.  This  is,  per- 
haps, the  most  prolific  source  of  pulp  irritation, 

2.  Mechanical  Irritation. — This  is  due  to  such  cases  as  abrasion, 
thermal  changes,  close  proximity  of  metallic  fillings,  injudicious 
regulating,  excessive  grinding,  etc. 

3.  Calcific  Deposits. — This  includes  pulp  nodules,  partially  cal- 
cified pulps,  and  secondary  dentin.  These  calcific  deposits  result 
from  slight  but  continued  irritation  of  the  pulpal  organ. 

4.  Crowning  Teeth  and  Filling  Large  Cavities. — It  is  usually  diffi- 
cult to  grind  a  vital  tooth  sufficiently  to  adjust  properly  the  band  for 
a  crown  without  irritating  the  pulp  and  thus  endangering  its  life. 
Sometimes  in  filling  teeth  it  is  advisable  to  remove  the  pulp  in  order 
to  properly  anchor  a  large  ffiling  or  inlay. 

314 


REMOVAL   OF  VITAL   PULPS    AND    SUBSEQUENT   TREATMENT      315 

5.  Pyorrhea  Alveolaris. — Frequently  in  treating  this  disease,  where 
the  teeth  are  acutely  sensitive  or  where  the  pockets  are  deep  and  the 
infection  in  the  apical  area  has  left  the  pulp  in  a  low  state  of  vitality, 
the  best  results  can  be  accompHshed  by  removing  the  organ,  and 
surgically  eradicating  the  pocket. 

General  Factors  to  be  Observed  in  Removal  of  Pulp. — Having 
considered  all  of  the  conditions  and  decided  that  the  removal  of  the 
pulp  is  indicated,  the  method  by  which  this  can  be  accomplished  with 
the  least  inconvenience  to  the  patient  and  to  the  operator  is  the  most 
important  consideration.  Whatever  method  is  employed  in  the  re- 
moval of  pulps  from  teeth  and  the  subsequent  treatment,  there  are 
at  least  three  factors  to  be  observed,  viz. : 

1.  Establish  and  maintain  asepsis  in  performing  the  operation. 

2.  Preserve  the  color  of  the  tooth. 

3.  Thoroughly  fill  the  root. 

There  are  two  general  methods  employed  in  the  removal  of  pulps 
— anesthetization  and  devitalization. 

I.  ANESTHETIZATION 

In  the  author's  opinion  a  method  of  removing  pulps  from  teeth, 
which  is  satisfactory  to  both  patient  and  operator,  all  things  con- 
sidered and  conditions  being  favorable,  is  to  anesthetize  the  tissue  by 
the  use  of  local  anesthetics  in  solutions  of  various  strengths.  The 
solutions  are  forced  or  carried  through  the  dentin  and  into  the  pulp 
by  means  of  pressure  or  the  electric  current.  In  exceptional  cases 
conductive  or  interosseous  anesthesia  may  be  employed. 

1.  PRESSURE  ANESTHESIA.— By  pressure  anesthesia  is 
meant  the  process  of  anesthetizing  the  pulp  by  forcing  solutions  of 
local  anesthetics,  usually  cocain  hydrochlorid,  into  the  tissue  by 
means  of  pressure.  The  pressure  is  applied  either  by  using  un- 
vulcanized  rubber  or  gutta-percha  and  a  blunt  instrument,  or  by 
specially  devised  instruments  for  this  purpose.  There  are  many 
such  instruments  on  the  market;  and  while  they  are  often  an  aid  in 
accomplishing  the  ultimate  result,  they  are  not  an  absolute  neces- 
sity. 

Sterilization. — The  rubber  dam  should  be  employed  in  every  case 
where  it  is  possible  to  adjust  it,  and  the  teeth  included  sterilized. 
In  cases  where  the  dam  cannot  be  adjusted,  it  would  doubtless  be 
best  to  remove  the  pulp  by  the  devitalization  method,  to  which 
reference  will  be  made  later,  for  in  using  the  method  under  consid- 
eration care  must  be  taken  to  prevent  pericementitis  following  the 


3l6  PRACTICAL   DENTAL   THERAPEUTICS 

operation;  and  one  of  the  precautions  to  be  observed  in  preventing 
this  result  is  to  thoroughly  sterilize  the  cavity  before  applying  the 
pressure.  It  should  be  remembered  that  the  majority  of  canals  which 
contain  live  pulps  are  sterile,  generally  speaking,  and  if  they  become 
septic  at  any  time  before  the  root  is  filled,  it  is  the  fault  of  the  operator ; 
hence  the  importance  of  always  adjusting  the  rubber  dam,  using 
sterile  instruments,  and  having  in  a  convenient  and  conspicuous 
place  an  antiseptic  doily  on  which  to  wipe  the  blood  and  dry  the 
instruments  used. 

Attention  is  again  directed  to  the  fact  that  the  usual  custom  of 
applying  coagulating  agents,  such  as  phenol,  cresol,  etc.,  to  the  cavity 
for  a  few  seconds  does  not  sterilize  the  dentin  to  the  degree  desired. 
The  best  results  are  accompUshed  by  employing  germicidal  agents 
which  are  soluble  in  water.  In  cavities  where  the  decay  is  not  too 
deep,  the  dentin  can  be  sterilized  by  the  use  of  a  lo  per  cent,  solution 
of  formaldehyd  to  which  5  per  cent,  of  sodium  borate  (borax)  or 
sodium  carbonate  has  been  added.  Where  the  decay  is  near  the  pulp 
this  solution  is  liable  to  cause  pain,  in  which  case  the  same  result  can 
be  accomplished  by  the  use  of  a  i :  500  solution  of  mercury  bichlorid 
or  a  1 :  200  solution  of  sublamin.  In  using  the  latter  solutions  the 
pliers  on  which  the  remedy  is  applied  should  be  wiped  immediately 
on  an  antiseptic  doily  to  prevent  the  mercury  from  acting  upon  the 
instrument.  One  of  the  best  solutions  with  which  to  chemically 
sterilize  the  dentin,  especially  in  those  cases  where  the  cavity  has 
previously  been  filled,  the  tubuli  are  closed,  and,  perhaps,  there  is 
secondary  dentin,  is  a  25  per  cent,  solution  of  sulphuric  acid.  Cook 
recommends  using  pure  sulphuric  acid  for  this  purpose.  The  solu- 
tion can  be  applied  to  the  floor  of  the  cavity,  being  careful  not  to  get 
the  agent  on  the  crown  of  the  tooth.  After  a  few  minutes  the  excess 
can  be  neutralized  with  a  solution  of  sodium  bicarbonate.  After 
the  dentin  is  sterilized  the  cavity  should  be  desiccated  with  warm 
alcohol  and  gentle  heat,  when  we  are  ready  to  use  the  anesthetizing 
solution.  Before  taking  up  the  technic  of  this  method,  however,  I 
desire  to  again  emphasize  the  importance  and  necessity  of  cavity 
sterilization.  In  our  discussion  later  of  the  devitalization  method, 
it  will  be  pointed  out  that  the  carious  and  infected  dentin  can  be 
completely  and  painlessly  removed  after  the  devitalizing  agent  has 
been  appHed,  thus  mechanically  sterilizing  the  cavity;  but  in  the 
anesthetization  method  the  infected  dentin  is  sensitive  and  cannot 
be  removed  without  unnecessarily  producing  pain.  The  dentin  in 
this  case  must,  then,  be  sterilized  by  chetnic  means,  for  to  force 
the  anesthetizing  solution  through    the  dentin  without  previously 


REMOVAL   OF  VITAL  PULPS   AND    SUBSEQUENT   TREATMENT      317 

sterilizing  it,  means  the  forcing  of  microorganisms  and,  perhaps,  poi- 
sonous ptomains  or  toxins,  into  the  pulp  tissue  and  many  times  into 
the  tissue  surrounding  the  apical  end  of  the  root,  for  it  is  difficult  to 
force  the  solution  to,  and  only  to,  the  apex;  thus  too  much  pressure 
and  the  lack  of  thorough  sterilization  constitute  a  proUfic  source  of 
pericementitis  following  the  removal  of  pulps  by  this  method. 
For  the  same  reason,  a  pulp  which  is  exposed  by  caries,  and,  therefore, 
undoubtedly  infected,  had  better  not  be  removed  by  pressure 
anesthesia. 

The  Solution. — With  the  cavity  thoroughly  steriHzed  we  are  now 
ready  to  use  the  anesthetizing  solution,  which  should  be  made  at  the 
time.  For  this  purpose  the  crystals,  previously  powdered,  or  flaked 
cocain  hydrochlorid  should  be  used  as  the  base,  and  freshly  distilled 
or  boiled  water  as  the  vehicle.  In  my  own  practice  I  use  "cocain 
points,"  which  are  compressed  points  or  cyHnders  of  pure  cocain 
hydrochlorid  containing  ^2  grain  (.005  Gm.)  each,  as  the  base  and 
my  regular  local  anesthetic  solution  as  the  vehicle  for  making  the 
stronger  solution.  A  prescription  for  the  regular  local  anesthetic 
solution  here  follows: 

I^ — Cocainae  hydrochloridi,  gr.  v  (0.3  Gm.) 

Sodii  chloridi,  gr.  j  (0.06  Gm.) 

Phenolis,  m.  ij  (0.13  mil) 

Aquae  menthse  piperitae,  fgj  (30  mils) — M. 

Sig. — Use  as  a  local  anesthetic  for  hypodermic  injections. 

There  are  many  advantages  in  using  the  anesthetic  agent  in  cylin- 
der form.  The  exact  amount  of  the  drug  used  is  known,  the  points 
are  readily  soluble  and,  in  many  cases,  they  can  be  conveniently 
placed  in  the  sterile  cavity  and  dissolved  therein,  either  in  the  serum  of 
the  blood,  if  an  exposure  exists,  or  in  the  vehicle  used  for  this  purpose. 
There  is  no  advantage  in  using  the  above  solution  rather  than  dis- 
tilled or  boiled  water  or  freshly  prepared  peppermint  water,  except 
that  the  solution  is  always  at  hand  in  a  convenient  container  and 
is  sterile.  Sterile  physiologic  salt  solution  is  an  excellent  vehicle 
for  making  the  anesthetic  solution. 

The  thumb  and  forefinger  with  which  cotton  is  to  be  wrapped 
around  the  broach  should  be  sterilized  by  dipping  a  large  pledget  of 
cotton  in  10  per  cent,  formaldehyd,  or  i :  500  mercury  bichlorid,  or 
1:200  sublamin  solution,  and  rolling  this  between  the  thumb  and 
finger.  A  cocain  point  or  a  small  amount  of  the  flaked  cocain  hy- 
drochlorid is  now  placed  on  a  clean  glass  slab  and  a  pledget  of  cotton, 
dipped  in  the  vehicle  selected,  a  few  drops  of  which  have  previously 
been  placed  on  one  end  of  the  glass  slab  or  in  a  clean  glass  watch- 


3l8  PRACTICAL   DENTAL   THERAPEUTICS 

crystal  or  other  container,  is  gently  placed  in  contact  with  the  alka- 
loidal  salt,  when  the  latter  readily  dissolves,  making  a  strong  solution. 
It  is  never  necessary  to  make  a  saturated  solution,  for  oftentimes 
better  results  will  be  obtained,  especially  if  the  solution  is  to  be  forced 
through  the  dentin,  if  the  strength  of  the  solution  approximates  only 
4  or  5  per  cent.  If  an  exposure  exists,  as  stated  above,  the  point  can 
be  placed  directly  in  contact  with  the  pulp  and  be  dissolved  in  the 
blood-serum. 

Pressure. — The  cotton  thus  saturated  is  placed  in  the  cavity  as 
nearly  over  the  pulp  as  possible.  A  piece  of  unvulcanized  rubber 
which  will  approximately  fill  the  cavity  is  selected  and  passed 
through  the  flame.  There  are  two  objects  in  doing  this:  It  sterilizes 
the  rubber  and  also  makes  it  more  pliable,  in  which  form  it  conforms 
readily  to  the  cavity  of  the  tooth.  The  rubber  is  now  placed  in  the 
cavity,  and  by  means  of  gentle  but  firm  pressure  with  a  suitable  blunt 
instrument  the  solution  is  forced  through  the  dentin  and  into  the  pulp. 
If  there  is  any  evidence  of  pain  as  the  pressure  is  applied,  it  should  be 
stopped  for  a  moment,  but  never  released.  The  slight  pain  is  only 
momentary  and  is  an  indication  that  the  solution  is  being  confined 
under  the  pressure,  which  is  essential  for  the  success  of  this 
method. 

It  may  be  necessary  in  those  cases  where  there  is  considerable  den- 
tin between  the  cavity  and  the  pulp  to  make  two  or  three  applications 
before  the  pulp  is  reached  without  pain,  after  which  one  application 
should  complete  the  thorough  anesthetization  of  the  organ.  After 
the  first  application  a  small  depression  can  be  drilled  into  the  dentin 
toward  the  pulp,  in  which  the  solution  can  subsequently  be  placed, 
thereby  aiding  materially  in  confining  the  solution  under  the  pressure. 
When  an  exposure  exists,  it  requires  but  little  pressure  to  anesthetize 
the  pulp.  In  these  cases  the  cocain  point  can  be  placed  in  the 
cavity  near  or  over  the  exposure  and  the  pulp  gently  pricked  with  a 
sharp  explorer,  causing  it  to  bleed;  this,  if  done  carefully,  will  produce 
very  little  pain.  The  blood-serum  will  dissolve  the  cocain  hydro- 
chlorid,  when  pressure  can  be  applied  and  the  pulp  anesthetized.  In 
doing  this,  however,  there  is  greater  danger  of  forcing  the  blood  into 
the  tubuli  of  the  dentin  of  the  crown  of  the  tooth,  thereby  making  it 
more  difficult  to  remove  the  blood.  Care  should  also  be  taken  not 
to  force  the  solution  any  further  than  is  necessary  for  the  painless 
removal  of  the  pulp,  and  it  should  here  be  again  noted  that  cocain  is  a 
general  protoplasmic  poison,  and  if  even  weak  and  sterile  solutions 
are  forced  past  the  apices  of  the  roots  pericementitis  is  almost  sure  to 
follow. 


REMOVAL   OF  VITAL   PULPS   AND    SUBSEQUENT   TREATMENT      319 

Confining  the  Solution  Under  Pressure. — In  removing  pulps 
by  pressure  anesthesia  without  employing  instruments  devised  for 
this  purpose,  the  best  results  are  obtained  in  cases  where  there  are 
four  walls  to  the  cavity,  for  in  this  condition  the  solution  is  easily  con- 
fined under  the  pressure.  In  proximo-occlusal  cavities,  the  missing 
wall  can  be  built  temporarily  with  gutta-percha  or  cement.  This  is 
seldom  necessary,  however,  if,  in  packing  the  rubber  in  the  cavity, 
care  be  taken  to  cover  the  gingival  wall  first  and  thus  seal  at  this  point, 
then  working  the  rubber  over  the  occlusal  and  gradually  creating  the 
pressure.  Whatever  means  are  adopted  for  the  purpose  of  confining 
the  solution,  we  must  avoid  having  the  solution  escape  at  the  gingival 
margin  of  the  cavity  and  thereby  be  forced  into  the  gum  tissue 
and  pericemental  membrane.  The  cause  of  much  pericementitis 
following  this  method  of  removing  pulps  can  be  traced  to  carelessness 
or  ignorance  in  this  regard. 

As  stated  elsewhere,  there  are  many  ingeniously  devised  instru- 
ments on  the  market,  the  use  of  which  is  often  a  material  aid  in  con- 
fining the  solution  under  pressure  and  forcing  it  through  the  dentin. 
The  same  precautions  should  be  observed  in  using  any  of  these  in- 
struments as  have  been  emphasized  in  the  application  of  pressure  by 
other  means. 

Opening  the  Pulp  Chamber  to  Expose  Canals. — When  the  pulp  is 
anesthetized,  the  pulp  chamber  should  be  opened  into  in  such  a 
manner  as  to  expose  the  canals.     This  is  best  accomphshed  with  a 


Fig.  14. — This  radiograph  shows  that  the  dentist,  in  opening  into  the  lower  first 
molar,  drilled  through  the  floor  of  the  pulp  chamber  and  exposed  the  tissue  between 
the  bifurcated  roots;  and,  as  a  result,  an  abscess  subsequently  developed.  The  case  was 
treated  by  sterilizing  and  stimulating  the  necrotic  area  between  the  roots  with  phenol- 
sulphonic  acid,  subsequently  flowing  eucapercha  compound  over  the  puncture  and 
packing  firmly  with  warm  base-plate  gutta-percha. 

large  round  or  inlay  bur  by  means  of  which  the  entire  roof  of  the 
chamber  can  be  obHterated.  A  bur  suggested  by  the  author  for  this 
purpose  is  simply  a  large  inlay  bur  with  the  end  rounded.  In  opening 
into  the  pulp  chamber  of  the  molar  teeth  care  should  be  taken  not  to 
disturb  the  floor  or  walls  of  the  chamber;  for  by  so  doing  we  are  hable 


320  PEACTICAL   DENTAL   THERAPEUTICS 

to  drill  through  the  bifurcation  or  the  mesial  or  distal  surface  of  the 
roots.  Even  if  such  disastrous  results  do  not  follow  the  destruction 
of  the  floor  or  walls  of  the  chamber,  it  at  least  adds  to  the  difi&culty  of 
entering  the  canals  with  a  broach.  (See  Fig.  14.)  While  we  are 
never  justified  in  drilling  unnecessarily  for  the  purpose  of  freely  expos- 
ing the  canals,  it  is,  if  necessary,  far  better  to  weaken  the  crown  of  the 
tooth  somewhat  by  this  means  rather  than  leave  a  portion  of  the  pulp 
in  an  inaccessible  canal  which  may  decompose  and  subsequently 
cause  an  infection  in  the  periapical  area. 

Selecting  and  Testing  Broaches. — The  selection  of  a  proper 
broach  is  an  important  matter.  Every  broach  should  be  tested  be- 
fore entering  the  canal.  This  can  be  done  by  bending  it  in  various 
directions.  If  the  broach  is  weak  in  any  particular  place  it  can  be 
detected  by  this  means;  thus  we  avoid  breaking  the  broach  in  the 
canal,  the  removal  of  which  is  often  a  difficult  procedure.  Many 
good  operators  claim  to  be  able  to  remove  all  pulps  by  using  a  smooth, 
three-cornered  broach  on  which  a  few  threads  of  cotton  are  wound. 
Others  use  twist  or  spiral  broaches.  In  all  large  canals  the  author 
has  had  the  most  satisfaction  from  the  use  of  a  barbed  broach.  The 
broach  should  be  gently  worked  along  the  side  of  the  canal  as  far  as  it 
will  go  without  using  too  much  force,  twisted  once  or  twice  to  en- 
tangle the  pulp,  and  then  withdrawn.  By  this  means  the  pulp  can  be 
removed  from  large  canals  in  its  entirety.  In  inserting  the  broach 
into  the  canal,  care  should  be  exercised  to  avoid  pushing  the  tissue 
before  the  broach  and  thus  pack  it  into  the  apical  area,  where  it 
is  difficult  of  removal.  Many  root-canals  have  been  imperfectly 
filled  and  abscesses  subsequently  developed,  because  of  the  fail- 
ure to  remove  all  of  the  pulp  tissue  at  the  time  it  was  anesthetized 
or  devitaHzed. 

Control  of  Ordinary  Hemorrhage  and  Removal  of  Blood. — In 
the  removal  of  Hve  pulps  by  the  anesthetization  method,  there  nec- 
essarily wiU  be  more  hemorrhage  than  in  those  cases  where  the 
pulp  is  devitaHzed  before  attempting  to  remove  it.  However,  the 
control  of  hemorrhage  is  not  as  difficult  a  procedure  as  many  writers 
have  led  us  to  believe.  In  most  cases  the  hemorrhage,  if  undisturbed, 
will  be  checked  by  Nature's  method  in  a  few  minutes,  after  which 
the  blood  in  the  cavity  and  canal  should  be  thoroughly  removed.  I 
desire  here  to  emphasize  the  importance  of  removing  the  blood.  One  of 
the  factors  to  be  observed  in  extirpating  pulps  from  teeth  and  the  sub- 
sequent treatment,  is  to  preserve  the  color  of  the  teeth.  The  cause  of 
many  teeth  darkening  after  the  pulp  has  been  removed  can  be  traced 
directly  to  the  failure  to  remove  the  blood  from  the  dentin  of  the 


REMOVAL   OF  VITAL   PULPS    AND    SUBSEQUENT   TREATMENT      32 1 

crown  of  the  tooth.  The  far  too  prevalent  practice  of  wiping  out  the 
bloody  canal  with  a  solution  of  hydrogen  dioxid,  bhndly  thinking  the 
blood  can  be  removed  by  this  means,  cannot  be  too  strongly  con- 
demned. The  hydrogen  dioxid  simply  decomposes  the  blood  within 
the  tooth-structure,  oxidizing  the  iron  of  the  hemoglobin ;  and  the  gases 
evolved  in  the  decomposition  force  this  pigment  into  the  tubuh,  which, 
if  left  (and  it  is  dij6&cult  to  remove  it),  will  cause  the  tooth  to  darken 
in  almost  every  instance.  Therefore,  we  should  avoid  forming  within 
the  tooth-structure  a  pigment  which  we  know  will  discolor  teeth. 
The  color  of  a  tooth  does  not  depend  upon  the  life  and  vitality  of  the 
pulp,  hut  upon  the  array  of  colors  in  the  dentin  which  are  reflected  through 
the  nearly  colorless  and  transparent  enamel.  If,  then,  these  colors  are 
not  changed  by  our  failure  to  remove  the  blood  or  by  the  use  of  stain- 
ing remedial  agents  in  the  treatment  subsequent  pulp  removal,  the 
tooth  will  not  discolor. 

To  remove  the  blood  from  the  canal,  alcohol  can  be  used,  or  even 
better  than  this  agent  is  Nature's  greatest  solvent,  water.  The 
water  should,  of  course,  be  sterile,  and  the  same  specimen  can  be  em- 
ployed here  as  was  used  in  making  the  anesthetizing  solution,  i.e., 
freshly  distilled  or  boiled  water,  or  peppermint  water  to  which  two 
minims  (0.12  mil)  of  phenol  have  been  added  to  the  fluidounce  (30.0 
mils).  Sterile  physiologic  salt  solution  is  perhaps  the  best  solution 
to  use  for  this  purpose.  By  this  means  the  blood  can  be  completely 
removed,  not  decomposed  in  the  canal  and  forced  into  the  structure  of 
the  tooth. 

Small  Canals. — There  are  many  canals  so  small  and  tortuous  that 
even  a  fine  broach  will  not  readily  enter,  to  any  depth  at  least.  In 
these  cases,  after  the  hemorrhage  from  the  larger  canals  has  been 
checked  and  the  blood  removed  it  is  well  to  stop  the  mouth  of  each 
with  cotton  or  temporary  stopping,  when  the  pulp  tissue  in  the  small 
canals  can  be  disorganized  by  the  use  of  strong  solutions  of  mineral 
acids  or  alkalies.  The  author  formerly  used  a  paste  of  sodium 
dioxid  and  dehydrated  (absolute)  alcohol,  placing  the  paste  in  the 
pulp  chamber  over  the  small  canals,  and  working  it  down  as  far  as 
possible  with  a  smooth  broach.  The  alcohol  gradually  evaporates, 
when  the  sodium  dioxid  can  be  decomposed  into  oxygen  and  caustic 
soda  by  placing  a  pledget  of  cotton  in  the  cavity  moistened  with  dis- 
tilled water.  After  the  reaction  has  taken  place,  the  alkali  can  be 
neutralized  with  a  weak  solution  of  sulphuric  acid  (2  per  cent.). 
This  process  can  be  repeated  until  the  desired  end  is  attained.  A 
more  convenient  preparation  to  use  here  is  a  saturated  solution  of 
potassium  or  sodium  hydroxid.     There  are  other  means  by  which  the 


32  2  PRACTICAL    DENTAL    THERAPEUTICS 

same  results  can  be  accomplished,  such  as  the  use  of  phenolsulphonic 
acid,  a  30  per  cent,  solution  of  chemically  pure  sulphuric  acid,  strong 
solutions  of  potassium  or  sodium  hydroxid,  or  a  mixture  of  metallic 
potassium  and  sodium  (Schreier's  paste).  For  reasons  mentioned 
later  under  the  Treatment  of  Pulpless  Teeth,  the  author  now  uses 
phenolsulphonic  acid.  These  same  agents  can  be  used  to  advantage 
for  the  purpose  of  disposing  of  a  remnant  of  a  pulp  in  larger  canals. 
It  is  not  safe  to  anesthetize  this  remnant  by  means  of  pressure.  The 
only  cases  on  record,  to  my  knowledge,  where  toxic  symptoms  have 
resulted  from  the  removal  of  a  pulp  by  pressure  anesthesia,  followed 
an  attempt  to  anesthetize  a  remnant  of  a  pulp  or  to  make  a  second 
application  of  the  anesthetizing  solution. 

After-treatment. — After  the  pulp  has  been  removed  and  the 
canals  dehydrated  with  modified  alcohol  and  heat,  an  anodyne  treat- 
ment is  indicated.  For  this  purpose  such  drugs  as  phenol,  oil  of 
cloves,  or  eugenol  can  be  employed.  The  author  suggests  here  euca- 
lyptol  compound.  In  using  any  of  these  remedies,  especially  the  last- 
named,  it  is  best  to  insert  dry  cotton  in  the  canal  and  then  place  a 
pledget  dipped  in  the  remedy  in  the  pulp  chamber  and  seal  with 
temporary  stopping  and  cement.  The  dry  cotton  in  the  canal  will 
absorb  the  moisture  from  the  apical  end  of  the  root  and  the  anodyne 
remedy  from  the  pulp  chamber.  There  is  an  advantage  in  using  the 
dry  cotton,  for  it  is  almost  impossible  to  completely  dehydrate  the 
canal  at  this  sitting.  If  asepsis  has  been  maintained  in  removing  the 
pulp,  all  that  is  necessary  is  to  keep  the  canal  in  this  condition  until 
the  root  can  be  filled;  therefore,  only  a  very  small  amount  of  the 
remedy  should  be  used.  The  tendency  here  is  to  use  too  much  with 
the  frequent  result  of  a  mild  active  hyperemia  in  the  pericementum. 
This  condition,  of  course,  soon  subsides,  but  it  is  always  best  to  pre- 
vent it  when  possible.  The  purpose  of  sealing  the  cavity  with  both 
temporary  stopping  and  cement  is  to  insure  hermetic  seaHng  of  the 
canal.  Eucalyptol  compound  has  no  advantage  here  over  other 
remedies  suggested  for  the  purpose  except  that,  besides  being  an  anti- 
septic, it  also  aids  in  the  hermetic  sealing.  The  heated  stopping  (good 
grade)  is  placed  immediately  over  the  eucalyptol  compound  dressing 
and  it  adheres  firmly  to  the  walls  of  the  cavity;  the  excess  is  removed 
and  the  remaining  portion  of  the  cavity  is  filled  with  cement. 

When  to  Fill  Canals. — The  canals  should  not  be  filled  at  the  sitting 
at  which  the  pulp  has  been  removed  by  pressure  anesthesia,  unless 
there  be  some  exceptional  reason  for  doing  so.  There  are  many 
good  reasons  why  the  canal  should  not  be  filled  at  this  sitting: 

I.  While  it  is  our  object  to  force  the  solution  just  sufficiently  to 


REMOVAL    OF  VITAL   PULPS   AND    SUBSEQUENT   TREATMENT      323 

anesthetize  the  pulp,  our  main  object  is  to  remove  the  pulp  absolutely 
without  pain;  and  it  is  very  difi&cult  to  force  the  solution  to  the  end 
©f  the  root  without  forcing  it  through  the  apex  to  some  extent  and 
anesthetizing  the  tissue  in  the  periapical  area.  With  the  tissue 
anesthetized,  we  would  have  no  guide  as  to  when  the  root  was 
thoroughly  filled. 

2.  The  tearing  away  of  the  pulp  from  its  connection  at  the  apex 
causes  more  or  less  irritation,  and  a  few  days  should  elapse  to  give 
Nature  a  chance  to  readjust  the  condition.  The  root-filHng  would 
only  serve  at  this  time  to  further  irritate  the  tissues. 

3.  Sometimes  with  the  utmost  care  in  removing  the  pulp,  second- 
ary hemorrhage  ensues  with  the  formation  of  a  clot  in  the  periapical 
area,  causing  soreness,  in  which  case  greater  comfort  can  be  given 
the  patient  by  the  proper  treatment  through  the  root-canal  than 
simply  by  counterirritation  or  ext-ernal  treatment  only. 

At  the  second  sitting,  the  case  giving  a  favorable,  history,  the 
canal  should  be  filled,  after  having  used  phenolsulphonic  acid  as 
explained  on  p.  344  under  Technic  of  Using  Acid-Method. 

Excessive  Hemorrhage.- — There  are  cases  occasionally  where 
Nature  does  not  stop  the  hemorrhage  as  readily  as  we  desire.  In 
these  exceptional  cases  the  hemorrhage  must  be  stopped  by  artificial 
means,  even  at  the  possible  expense  of  producing  pericementitis. 
Cauterizing  agents  are  useful  here.  For  this  purpose  95  per  cent, 
phenol  or,  what  is  still  better,  phenolsulphonic  acid  can  be  worked 
down  into  the  canal  against  the  injured  and  bleeding  tissue,  after  which 
the  acid  should  be  neutralized  with  a  solution  of  sodium  bicarbonate 
(10  per  cent.)  and  an  anodyne  treatment  employed  as  usual.  Where 
the  above  treatment  does  not  produce  the  desired  result,  cotton  satu- 
rated with  a  fresh  i :  1,000  solution  of  adrenalin  chlorid  can  be  placed  in 
the  canal  and  with  unvulcanized  rubber  forced  into  the  tissue  beyond 
the  end  of  the  root.  This  agent  should  only  be  used  in  extreme 
cases  because  of  the  soreness  and  injurious  effect  it  is  Hable  to  produce 
upon  the  tissues  involved. 

Objections  to  the  Use  of  Adrenalin  Chlorid. — In  this  connection 
I  desire  to  discuss  the  use  of  solutions  of  adrenaUn  chlorid  as  the 
vehicle  for  making  the  anesthetizing  solution,  or  the  use  of  adrenahn 
chlorid  and  cocain  hydrochlorid  tablets  for  anesthetizing  the  pulp. 
The  adrenalin  chlorid  has  been  suggested  as  a  means  of  preventing 
hemorrhage.  Now,  it  ought  to  be  evident  to  anyone  who  has  studied 
this  subject  that,  to  prevent  hemorrhage  by  the  use  of  any  st5^tic  or 
hemostatic  agent,  it  is  necessary  to  force  the  agent  into  the  tissue 
from  which  the  hemorrhage  comes.     Therefore,  to  get  the  effect  of 


324  PRACTICAL   DENTAL   THERAPEUTICS 

the  adrenalin  chlorid  in  removing  pulps  by  pressure  anesthesia,  it  is 
absolutely  essential  that  the  anesthetizing  solution,  which  also  con- 
tains the  hemostatic  agent,  be  forced  through  the  apex  and  into  the 
periapical  area — the  very  thing  we  have  been  taught,  from  sad  experi- 
ence, not  to  do.  When  we  remember  that  the  majority  of  pulps  we  are 
called  upon  to  remove  are  those  in  which  there  is,  or  has  been,  more 
or  less  pulpitis,  and  when  we  remember  also  that  pathology  teaches 
that  this  condition  is  frequently  associated  with  pericementitis,  it  is 
questionable  whether  or  not  we  ought  to  prevent  hemorrhage  in  re- 
moving pulps  from  teeth.  For  to  permit  the  escape  of  blood  from  the 
hyperemic  tissue  at  the  end  of  the  root  is  one  of  the  best  means  of 
aiding  Nature  to  readjust  the  abnormal  to  the  normal  condition.  In 
case  the  primary  hemorrhage  has  been  prevented  by  the  use  of 
hemostatic  agents,  such  as  adrenalin  chlorid,  secondary  hemorrhage 
is  almost  certain  to  follow  with  the  formation  of  a  clot,  the  absorption 
of  which  in  the  periapical  area  is  an  extremely  slow  and  tedious- 
process. 

2.  CATAPHORESIS. — Cataphoresis,  as  has  been  elsewhere  ex- 
plained, is  a  term  appUed  to  the  process  of  carr3dng  medicinal  agents 
in  solution  into  the  various  tissues  and  organs  of  the  body  by  means 
of  the  electric  current.  Formerly  there  was  a  variety  of  cataphoric 
outfits  on  the  market.  To  anesthetize  a  pulp  by  this  means  the  tooth 
should  be  insulated  by  the  rubber  dam,  care  being  taken  that  no 
moisture  escapes  from  the  gum.  A  small  pledget  of  cotton  saturated 
with  the  anesthetizing  solution  is  now  placed  in  the  cavity,  the  posi- 
tive pole,  or  anode,  apphed  to  the  solution,  and  the  negative  pole,  or 
cathode,  moistened  with  water,  applied  to  some  part  of  the  patient's 
body,  usually  the  hand,  thus  completing  the  circuit,  A  steady  and 
continuous  current  is  desired,  and  the  perfected  instruments  are  so 
devised  that  the  amount  of  current  can  be  measured.  The  time  re- 
quired to  anesthetize  the  pulp  by  this  means  depends  largely  upon  the 
density  of  the  dentin  and  the  perfection  of  the  instruments  used. 
With  the  pulp  anesthetized,  the  same  method  of  removal  and  of 
subsequent  treatment  is  followed  as  in  pressure  anesthesia.  Cata- 
phoresis, while  successful  in  the  hands  of  those  who  mastered  the 
technic,  never  became  popular,  largely  because  of  the  time  required 
to  accomplish  the  result  and  because  of  the  complicated  and  expensive 
apparatus  necessary. 

If  the  method  of  anesthetizing  the  pulp  be  followed  and  the  pre- 
cautions observed,  as  detailed  here,  it  will  be  found  that  there  are  few 
pulps  which  will  not  yield  to  the  influence  of  cocain  hydrochlorid 
applied  directly  by  means  of  pressure.     It  takes  time,  however,  to 


REMOVAL    OF  VITAL   PULPS   AND    SUBSEQUENT   TREATMENT      325 

adjust  the  rubber  dam,  sterilize  the  cavity,  remove  the  pulp  and 
blood  from  the  canal  and  seal  in  the  anodyne  remedy.  Many  times 
the  operator  is  not  able  at  this  sitting  to  give  the  necessary  time 
to  complete  this  operation.  There  are  cases  also  where  the  condition 
or  the  location  of  the  tooth  in  the  mouth  is  such  as  to  favor  the  re- 
moval of  the  pulp  by  another  method,  which  will  now  be  considered. 

n.  DEVITALIZATION 

In  discussing  Sensitive  Dentin  under  the  subject  of  escharotics  or 
caustics,  reference  was  made  to  the  fact  that  there  are  many  drugs 
belonging  to  this  class  of  agents  that  cannot  be  employed  in  the  treat- 
ment of  sensitive  dentin,  for  the  reason  that  they  are  penetrating 
and  have  the  same  deleterious  effect  upon  the  cells  of  the  pulp  tissue 
as  upon  the  dentinal  fibrillae.  Some  of  the  agents  which  cannot  be 
*  used  for  allaying  the  sensitiveness  of  dentin  are  exceedingly  valuable 
and  are  employed  for  the  purpose  of  destroying  the  vitality  of  the 
pulp,  thus  aiding  in  its  painless  removal.  The  most  prominent  of 
these  agents  is  arsenic  trioxid  (AS2O3),  formerly  called  arsenious  acid. 
The  use  of  this  agent  in  the  treatment  of  sensitive  dentin  was  first  ad- 
vocated by  Dr.  Spooner,  of  Montreal,  who  discovered  that  by  seaHng 
the  drug  in  a  cavity  for  a  few  days  the  most  sensitive  dentin  yielded 
to  its  influence.  The  fact,  however,  that  nearly  all  teeth  thus  treated 
subsequently  gave  trouble  because  of  the  death  of  the  pulp  and  the 
usual  sequelae,  led  the  profession  to  abandon  this  agent  for  the  pur- 
pose for  which  it  was  introduced;  but  it  has  ever  since  been  used  as  a 
means  of  destroying  the  vitality  of  the  pulp.  In  fact,  for  years  it  was 
the  only  agent  employed  with  any  satisfaction. 

At  the  present  time  there  is  considerable  discussion  in  dental  litera- 
ture as  to  whether  or  not  the  effects  of  arsenic  trioxid  when  applied 
to  a  dental  pulp  are  self-limiting.  Some  men  of  high  standing  in  the 
profession  are  of  the  opinion  that  the  drug  is  too  destructive  an  agent 
to  be  used  for  the  purpose  of  pulp  devitahzation.  It  seems  to  the 
author  that  these  opinions  are  not  well  founded  when  we  consider  the 
long  clinical  record  of  the  drug  as  a  devitalizing  agent.  It  has  been 
used  since  1836.  There  can  be  no  question  regarding  the  harmful 
effects  of  the  drug  when  injudiciously  employed.  Its  action  is  not 
self-limiting.  Its  effects  are  produced  only  after  the  drug  is  absorbed 
by  the  tissue  elements,  altering  or  destroying  their  vital  processes  in 
an  obscure  manner.  The  reason  why  the  drug  may  be  safely  em- 
ployed in  devitalizing  the  pulp  of  a  fully  erupted  tooth  lies  in  the  fact 
that  here  the  effects  are  confined  to  the  pulp  tissue,  since  the  organ 


326  PRACTICAL    DENTAL    THERAPEUTICS 

dies  by  strangulation  at  the  apex  due  to  the  congestion  caused  by  the 
drug  when  so  used.  Thrombosis  and  death  of  the  pulp  take  place; 
and,  owing  to  the  small  foramina  of  the  tooth-root,  absorption  of  the 
drug  by  continuity  of  tissue  is  prevented.  In  those  cases  where  the 
apices  of  the  roots  are  not  fully  formed  the  drug,  if  used  at  all,  should 
be  left  sealed  in  the  tooth  only  a  short  time.     Fig.  15  shows  the 


Fig.  15. — Tooth  and  alveolar  process  exfoliated  as  a  result  of  arsenical  poisoning. 

results  of  arsenic  trioxid  having  been  left  in  such  a  tooth  for  too  long 
a  period  of  time.  Fig.  16  proves  that  the  drug  may  be  safely  used 
if  the  proper  precautions  are  observed. 


Fig.  16. — The  pulp  in  the  second  bicuspid  was  devitalized,  canal  treated,  and  filled 
by  the  author  in  September,  1902.  The  molar  had  been  treated  by  an  unknown  den- 
tist previous  to  this  time.  The  radiograph  was  taken  March  28, 1916,  fourteen  and  one- 
half  years  after  root-canal  operation  on  bicuspid.     Tooth  has  always  been  comfortable. 

The  Preparation. — Much  difficulty  has  been  experienced  in  the 
use  of  arsenic  trioxid,  largely  because  of  the  uncertainty  of  the 
preparations  employed.  Many  arsenical  preparations  are  on  the 
market.  The  white  powder  can  be  used  by  moistening  a  small 
pledget  of  cotton  with  some  liquid,  such  as  phenol,  cresol,  creosote,  or 
oil  of  cloves;  then  by  touching  the  cotton  to  the  powdered  arsenic 
trioxid,  a  sufficient  amount  will  adhere  which  should  be  transferred 
to  the  cavity  and  sealed,  preferably  with  cement.  It  is  well  for  each 
operator  to  select  an  arsenical  preparation  with  which  he  can  obtain 


REMOVAL    OF  VITAL   PULPS    AND    SUBSEQUENT   TREATMENT      327 

good  results,  and  then  this  should  be  used  to  the  exclusion  of  all 
others.  By  this  means  only  can  we  become  thoroughly  familiar  with 
the  action  of  the  preparation  employed.  The  following  formula  is 
here  given  for  those  who  prefer  a  paste : 

I^ — Arseni  trioxidi,  5j  (4-o  Gm.) 

Cocainae,  gr,  x  (0.6  Gm.) 

Thymolis,  gr.  v  (0.3  Gm.) 

Petrolati,  gr.  x  (0.6  Gm.)— M. 
Fiat  Unguenta. 
Sig. — Apply  a  small  amount  to  the  dentin  immediately  over 
the  pulp. 

I  wish  to  state  here  something  about  the  pharmacy  of  this  pre- 
scription, for,  if  the  preparation  does  not  work  satisfactorily,  it  has  not 
been  properly  compounded.  Arsenic  trioxid  is  the  base;  cocain  is  a 
local  anesthetic,  and  when  applied  to  the  pulp  produces  a  condition 
of  analgesia  by  which  the  irritating  action  of  the  arsenic  trioxid  is 
without  effect,  and  thus  prevents  the  tooth  from  aching  while  the 
pulp  is  being  devitalized.  With  the  alkaloidal  cocain  and  thymol, 
together  with  this  amount  of  petroleum,  a  nice  paste  can  be  made  with 
the  arsenic  trioxid.  The  author  prefers  a  fiber  which  is  made  from 
the  same  formula  as  above  by  thoroughly  incorporating  it  in  some 
fibrous  vehicle.  The  fiber  may  be  stained  so  that  it  will  be  of  a  dif- 
ferent color  from  the  ordinary  cement,  which  is  used  to  seal  the 
preparation  in  the  cavity. 

Technic  of  Application. — In  those  cases  of  pulpitis  where  the  tooth 
has  ached  before  the  patient  presents  for  treatment,  it  is  always  the 
best  practice  to  allay  the  pain  for  at  least  twenty-four  hours  before 
attempting  to  devitalize  the  pulp.  If  for  any  reason  this  cannot  be 
done  conveniently  and  it  is  deemed  best  to  make  the  arsenical  appli- 
cation at  this  sitting,  the  engorged  capillaries  may  be  reheved  by  ad- 
ministering two  or  three  doses  of  nitroglycerin,  letting  about  one  hour 
intervene  between  the  doses.  This  will  also  tend  to  mitigate  the 
pain  which  sometimes  accompanies  the  devitalization  of  the  pulp. 
The  pain  in  these  cases  of  pulp  congestion  can  be  absolutely  controlled 
by  carefully  excavating  until  the  pulp  is  exposed ;  then  apply  one-half 
of  a  "cocain  point"  to  the  exposure,  permitting  the  serum  to  dissolve 
the  drug,  after  which  the  arsenical  application  may  be  made  in  the 
usual  manner.  In  any  case,  whether  the  tooth  has  ached  or  not, 
before  applying  the  arsenical  preparation  or  before  adjusting  the 
rubber  dam,  it  is  best  to  break  down  all  overhanging  edges  of  enamel 
and  carefully  remove  or  wash  out  with  a  nonirritating  antiseptic  solu- 
tion any  food-stuffs  or  debris  which  may  be  in  the  cavity.     Food- 


328  PRACTICAL   DENTAL   THERAPEUTICS 

stuffs  contain  albumin,  and  if  this  is  in  the  cavity  of  the  tooth  when 
the  arsenical  preparation  is  applied,  the  arsenic  trioxid  will  act  upon 
the  albumin,  forming  arsenic  albuminate,  and  >  thereby  a  certain 
amount  of  the  agent  is  neutralized  or  becomes  inert.  As  much  of  the 
carious  dentin  should  also  be  removed  as  can  be  done  without  pro- 
ducing pain,  for  the  application  should  be  made  to  a  sensitive  spot  in 
the  cavity.  It  is  never  necessary  to  have  an  exposure  of  the  pulp;  and 
in  case  an  exposure  exists,  it  is  just  as  well  to  apply  the  preparation 
to  the  dentin  immediately  over  the  pulp,  rather  than  to  the  organ  it- 
self, though  in  using  the  fiber  suggested  here  there  is  no  logical 
reason  why  it  should  not  be  applied  directly  to  the  exposed  pulp. 
In  any  event  the  preparation  should  be  covered  with  cotton  or  a  small 
metallic  or  paper  disk  to  prevent  pressure  and  also  to  prevent  the 
phosphoric  acid  of  the  cement  from  coming  in  contact  with  the  in- 
gredients of  the  preparation. 

Length  of  Time  Application  Should  Remain. — There  are  at  least 
four  factors  which  govern  the  length  of  time  an  arsenical  application 
should  remain  sealed  within  a  tooth,  viz.: 

1.  The  age  and  general  condition  of  the  patient. 

2.  The  general  condition  of  the  pulp  itself. 

3.  The  amount  and  condition  of  the  dentin  intervening  between 
the  pulp  proper  and  the  application  of  the  preparation. 

4.  The  climate  or  season  of  the  year,  strange  as  it  may  seem,  in- 
fluences the  action  of  arsenic  trioxid. 

Taking  into  consideration  these  various  factors,  the  arsenical 
preparation  should  remain  in  the  cavity  from  one  to  four  days.  At 
the  second  sitting  the  rubber  dam  should  be  adjusted,  the  teeth  in- 
cluded sterilized,  and  the  cement  and  preparation  removed,  after 
which  every  surface  of  the  cavity  should  be  freshened  with  a  large 
round  bur.  This  not  only  insures  the  thorough  removal  of  the  arsen- 
ical preparation,  which,  should  a  portion  remain,  is  liable  to  produce 
pericemental  inflammation,  but  it  also  mechanically  sterilizes  the 
cavity  by  removing  the  carious  and  infected  dentin.  This  is  impor- 
tant and  is  an  aid  in  maintaining  asepsis  in  the  removal  of  the  pulp. 
In  the  author's  judgment,  this  is  much  better  practice  than  to  depend 
upon  a  solution  of  dialysed  iron  to  neutralize  the  arsenic  trioxid. 

Opening  Pulp  Chamber  and  Exposing  Canals. — The  pulp  chamber 
can  now  be  opened,  observing  practically  the  same  details  as  were 
explained  under  the  anesthetization  method.  Oftentimes,  in  the 
initial  opening  into  the  pulp  chamber,  and  sometimes  on  entering  the 
canal,  after  the  application  of  arsenic  trioxid,  the  patient  will  expe- 


REMOVAL   OF  VITAL   PULPS   AND    SUBSEQUENT   TREATMENT      329 

rience  some  pain.  This  condition  should  be  anticipated ;  for  the  safest 
method  of  devitalizing  pulps  with  arsenic  trioxid  is  to  leave  the  drug 
sealed  in  the  tooth  only  srffficiently  long  to  poison  the  tissue — not 
completely  devitalize  it;  and  depend  upon  the  subsequent  application 
of  some  remedy  containing  formaldehyd  to  complete  the  devitaliza- 
tion. For  this  purpose  the  author  uses  formocresol.  This  remedy 
should  be  left  in  contact  with  the  tissue  for  about  three  days.  The 
formaldehyd  generated  from  formocresol  not  only  completes  the 
devitalization  of  the  tissue;  but  it  also  desiccates  and  toughens  it, 
which  faciHtates  its  subsequent  removal.  Strange  as  it  may  seem,  in 
those  cases  of  arsenical  soreness  where  the  arsenic  trioxid  had  been 
left  in  the  tooth  for  too  long  a  period,  formocresol  will  absolutely 
correct  the  soreness.  The  clinical  experience  of  the  author  leads  him 
to  believe  that  formaldehyd  acts  here  as  a  chemic  antidote  for  arsenic 
trioxid.  At  the  subsequent  sitting  the  tissue  may  be  removed,  and 
phenolsulphonic  acid  employed  to  enlarge  the  canals  and  remove 
therefrom  every  vestige  of  organic  matter,  when  the  canals  should 
be  filled. 

Objections  to  the  Use  of  Dialysed  Iron  and  Tannic  Acid. — In 
connection  with  the  preservation  of  the  color  of  the  tooth,  under  the 
anesthetization  method  the  author  stated  his  objection  to  the  use  of 
hydrogen  dioxid  for  removing  the  blood  from  the  cavity  and  canal. 
It  is  necessary  here,  also,  to  refer  briefly  to  a  well-established  practice 
of  treating  teeth  after  the  pulps  have  been  devitalized.  It  is  the 
practice  of  many  dentists,  after  removing  the  arsenical  dressing,  to 
flood  the  cavity  with  a  solution  of  dialysed  iron,  after  which  the  pulp 
chamber  is  opened,  which  usually  produces  some  hemorrhage;  then, 
without  any  especial  effort  being  made  to  remove  the  dialysed  iron 
or  blood,  tannic  acid  in  some  form  is  sealed  in  contact  with  the  pulp 
for  a  week  or  ten  days,  it  being  deemed  advantageous  to  constringe 
and  toughen  the  tissue  by  this  means  before  attempting  its  removal. 
Let  us  consider  the  rationalism  of  such  treatment.  The  pulp  tissue 
in  all  large  canals  is  sufficiently  tough  to  be  removed  in  its  entirety, 
and  it  must  be  disorganized  or  removed  piecemeal  in  small  canals, 
whether  it  has  been  previously  constringed  or  not.  Hence,  there  is 
no  advantage  in  using  tannic  acid,  and  there  is  a  serious  objection. 
If  those  who  follow  this  practice  are  observing,  they  will  notice  that 
after  removing  the  tannic  acid  dressing  the  pulp  tissue  is  dark  in 
appearance.  They  will  also  observe  that  many  teeth  thus  treated 
subsequently  discolor.  The  cause  for  this  is  found  in  the  fact  that 
tannic  acid  and  iron,  in  any  form,  are  chemically  incompatible,  the 
resulting  compound  being  iron  tannate,  one  of  the  most  insoluble  sub- 


330  PRACTICAL   DENTAL   THERAPEUTICS 

stances  known  to  chemistry.  In  the  presence  of  moisture  a  form 
of  ink  is  produced  which  is  a  great  staining  agent  for  dentin,  and 
one  that  it  is  almost  impossible  to  remove  by  any  known  process  of 
bleaching. 

As  has  been  stated  elsewhere,  there  are  cases  where,  for  want  of 
time  or  other  reasons,  the  pulp  can  be  removed  to  advantage  by  de- 
vitalization; however,  when  this  method  is  followed  tannic  ?cid 
should  not  be  used,  and  every  trace  of  dialysed  iron  (if  used  at  all,  and 
it  is  unnecessary  to  use  it)  and  blood  should  be  removed  with  alcohol 
or  water. 

COMPLICATIONS.— In  our  discussion  thus  far  of  the  methods 
of  removing  pulps  from  teeth,  we  have  considered  only  favorable 
cases,  selecting  the  method  best  adapted  to  the  case  at  hand.  There 
are  many  instances,  however,  where  it  is  difficult  to  remove  the  pulp 
by  either  the  anesthetization  or  devitalization  method,  at  least  until 
the  tooth  is  placed  in  a  more  favorable  condition. 

Hypertrophied  Gtim  Tissue. — Oftentimes  in  approximating  cavi- 
ties the  decay  in  one  or  both  teeth  has  extended  far  beneath  the  gum, 
the  rough  gingival  margin  of  the  cavity  acting  as  a  slight  irritant  by 
which  the  gum  tissue  is  stimulated,  causing  it  to  proliferate  until  it 
fills  a  portion  of,  and  in  some  instances  the  entire,  cavity.  In  such 
cases  the  first  consideration  is  to  dispose  of  the  hypertrophied  tissue. 
Where  the  gum  fills  only  a  portion  of  the  cavity  and  the  pulp  of  the 
tooth  is  not  causing  trouble,  the  cavity  should  first  be  enlarged 
and  washed  with  a  warm  antiseptic  solution,  after  which  it  should  be 
dried  as  well  as  possible  and  packed  with  warm  gutta-percha.  But 
in  those  cases  where  the  gum  tissue  occupies  the  entire  cavity,  and 
especially  where  the  tooth  is  aching,  it  should  be  removed  at  once. 
The  electric  cautery  is  doubtless  the  best  means  to  use  for  disposing 
of  this  tissue.  It  is  practically  painless  and  no  hemorrhage  follows 
its  use,  which  is  an  advantage.  In  the  absence  of  this,  other  means 
may  be  employed.  Hypertrophied  gum  tissue  is  quite  tough  and 
fibrous,  and  if  it  is  elevated  or  pushed  back  by  means  of  a  flat  instru- 
ment, it  will  usually  be  found  that  the  attachment  at  the  gingival 
margin  is  small  and  can  easily  be  severed  by  employing  gum  scissors 
or  a  lancet,  previously  dipped  in  phenol.  It  is  best  not  to  tell  the 
patient  what  you  are  going  to  do,  for  scarcely  any  pain  will  be  experi- 
enced. The  hemorrhage  in  these  cases  is  usually  profuse,  but  caii 
readily  be  stopped  by  cauterization  with  95  per  cent,  phenol  or  a  50 
per  cent,  solution  of  phenolsulphonic  acid.  The  blood  should  now  be 
thoroughly  removed,  the  cavity  dried,  moistened  with  eucalyptol, 
and  packed  with  gutta-percha,  letting  it  extend  buccally  and  Hngually 


REMOVAL   OF  VITAL   PULPS    AND    SUBSEQUENT   TREATMENT     33 1 

to  fill  the  interproximal  space.  The  gutta-percha  can  be  removed 
from  the  interior  of  the  cavity  with  a  heated  flat  instrument.  Quite 
often  the  most  practical  way  of  adjusting  the  rubber  dam  in  these 
cases  is  to  place  the  clamp  on  the  tooth  posterior  to  the  one  thus 
packed,  letting  a  single  hole  in  the  dam  include  both  teeth.  The  pack- 
ing, if  properly  placed,  will  prevent  leakage.  The  pulp  can  now  be 
removed  by  the  method  which  the  operator  deems  the  most  feasible. 

It  might  be  mentioned  in  this  connection  that  hypertrophied  gum 
tissue  may  and  frequently  does  occur  from  irritants  other  than  rough- 
ened cavity  margins  near  the  gingivae.  The  condition  results  from 
chronic  inflammation  of  the  gums  and  from  such  mechanical  irri- 
tants as  salivary  and  serumal  deposits,  ill-fitting  crowns,  bridges  and 
partial  dentures.  Certain  constitutional  conditions  may  also  pro- 
duce h37pertrophy  of  the  gums.  Among  these  may  be  mentioned 
scurvy,  mercurial  poisoning  and  malnutrition,  especially  in  children 
and  particularly  among  the  poor  in  large  cities.  Marshall^  classifies 
hypertrophy  of  the  gums  as  a  precancerous  lesion  and  says,  "Me- 
chanical irritation  is  dangerous  and  should,  therefore,  be  removed 
at  once." 

Importance  of  a  Correct  Diagnosis  as  to  the  Kind  of  Tissue 
in  a  Cavity. — There  is  one  instance  in  the  removal  of  pulps  from  teeth 
where  students,  particularly,  are  liable  to  make  a  serious  mistake  if 
they  are  not  extremely  careful.  This  is  in  cases  where,  in  large 
occlusal  cavities,  especially  in  lower  first  molars  of  children,  the  pulp 
has  died  and  the  decay  has  extended  through  the  bifurcation  of  the 
roots,  leaving  rough  edges  which  continually  irritate  the  tissue,  caus- 
ing it  to  proliferate  and  ultimately  fill  the  cavity.  To  carelessly 
force  the  anesthetizing  solution  into  such  a  cavity,  where  the  pulp  in 
the  canals  is  gangrenous,  would  be  the  means  of  causing  an  acute 
alveolar  abscess.  The  apphcation  of  arsenic  trioxid  would  mean  the 
loss  of  at  least  one  tooth,  perhaps  one  or  two  on  either  side  of  the 
one  to  which  the  application  is  made,  with  a  portion  of  the  alveo- 
lar process. 

Before  applying  either  the  anesthetizing  or  devitalizing  agent,  a 
correct  diagnosis  should  be  made;  we  should  ascertain  definitely  the 
kind  of  tissue  in  the  cavity.  With  a  little  experience  this  is  usually  a 
simple  matter.  The  history  of  the  case  as  related  by  the  patient 
will  often  serve  as  a  guide.  Pulp  tissue  is  generally  more  sensitive 
than  gum  tissue,  and  when  slightly  pricked  with  a  sharp  instrument 
bleeds  more  profusely.  If  the  tissue  proves  to  be  hypertrophied 
gum  tissue  it  can  be  disposed  of  in  the  usual  manner,  the  puncture 

^Pacific  Dental  Gazette,  November,  1916. 


332  PRACTICAL    DENTAL    THERAPEUTICS 

closed  temporarily  with  cement  or  gutta-percha  and  the  tooth  treated 
as  the  condition  necessitates  (see  Fig.  14).  When  this  cannot  be 
accompHshed,  and  the  tooth  kept  free  from  infection,  it  should  be 
extracted. 

Hypertrophied  Pulp  Tissue. — In  cases  where  the  tissue  is  hyper- 
trophied  pulp  tissue,  it  will  generally  be  found  unusually  resistant  to 
both  cocain  hydrochlorid  and  arsenic  trioxid,  and  it  is  sometimes 
necessary  to  resort  to  interosseous  or  conductive  anesthesia,  or  to  the 
administration  of  such  general  anesthetics  as  nitrous  oxid  and  oxygen, 
in  order  to  painlessly  remove  the  tissue. 

Secondary  Dentin,  Pulp  Nodules,  and  Pulp  Calcification. — Quite 
frequently  we  find  cases  where  it  seems  almost  impossible  to  force  the 
anesthetizing  solution  through  the  dentin  and  into  the  pulp,  and 
when  arsenic  trioxid  is  applied  it  has  little  or  no  effect.  In  these  cases 
we  can  suspect  that  the  pulp  has  receded  because  of  some  sHght  but 
continued  external  irritation,  the  space  being  filled  in  with  secondary 
dentin,  the  tubuli  of  which  are  irregular  and  do  not  run  at  right  angles 
to  the  base  upon  which  they  rest,  as  in  the  normal  dentin.  Occasion- 
ally cases  will  present  where  the  entire  canal  has  been  obHterated 
(see  Fig.  6  and  p.  303).  This  condition  is  more  often  found  in 
elderly  patients.  As  a  result  also  of  external  irritation,  pulp  nodules 
and  pulp  calcification  are  sometimes  encountered.  In  removing 
the  pulp  in  these  cases,  often  the  most  painless  and  best  results 
are  obtained  only  by  a  combination  of  both  the  anesthetization  and 
devitahzation' methods;  for  the  removal  of  these  pulp  nodules  and 
calcified  pulps  is  often  a  difficult  procedure.  After  we  have  used 
cocain  hydrochlorid  and  pressure  or  previously  applied  arsenic  trioxid 
and  anesthetized  or  devitalized  a  portion  of  the  pulp,  we  may  be  able 
to  reach  the  pulp  nodule  or  nodules  without  producing  pain.  But 
frequently  these  calcific  bodies  are  agglutinated,  and  close  the  mouth 
of  the  canal;  especially  is  this  condition  found  in  the  molar  teeth. 
The  pulp  tissue  immediately  under  the  nodule  is  extremely  sensitive. 
In  such  a  case  the  anesthetizing  solution  could  not  be  forced  into  the 
canal  without  first  removing  the  obstruction,  and  arsenic  trioxid,  if 
applied,  would  have  no  effect.  These  are  cases  which  require  much 
perseverance  and  patience  on  the  part  of  both  patient  and  operator. 
The  nodule  can  sometimes  be  loosened  by  gently  working  around  it 
with  an  exploring  or  other  suitable  instrument.  The  author  has  met 
with  success  by  taking  a  small  round  bur  and  drilling  past  the  nodule, 
care  being  taken  not  to  puncture  the  root,  then  with  the  engine  run- 
ning rapidly  the  nodule  is  tapped  and  dislodged.  When  the  obstruc- 
tion in  the  pulp  chamber  and  canals  is  removed  the  remaining  tissue 


REMOVAL   OF  VITAL   PULPS    AND    SUBSEQUENT   TREATMENT      333 

can  be  anesthetized  or  devitalized  in  the  usual  manner.  If  the  de- 
vitalization method  is  employed,  the  arsenical  preparation  can  be 
placed  over  the  mouth  of  the  canal  with  safety;  but  it  is  never  advis- 
able to  place  the  preparation  down  in  the  canal.  In  extreme  cases 
it  may  be  necessary  to  inject  local  anesthetics  by  the  conductive  or 
interosseous  methods,  and  thus  anesthetize  the  pulps,  or  nitrous  oxid 
and  oxygen  may  be  administered. 

REMOVAL  OF  PULPS  FROM  DECIDUOUS  TEETH 

There  is,  perhaps,  no  dentist  who  has  been  in  practice  for  any 
length  of  time  but  has  been  called  upon  to  remove  an  exposed 
pulp  from  a  deciduous  tooth.  With  the  so-called  ''horrors  of  the 
dental  chair"  magnified  in  the  child's  mind,  as  is  too  generally  the 
case,  this  is  not  often  the  most  pleasant  thing  the  dentist  is  called 
upon  to  do.  The  question  resolves  itself  largely  into  the  proper  hand- 
ling of  the  child.  Any  expedient  may  be  employed  to  gain  the  con- 
fidence of  the  little  patient,  after  which  either  anesthetization  or 
devitaHzation  may  be  used  as  is  deemed  best  under  the  conditions. 
Generally  the  latter  method  is  preferable;  and  it  will  be  found  that 
the  pulps  are  peculiarly  susceptible  to  the  action  of  arsenic  trioxid. 
The  preparation  should  not  be  left  in  the  tooth  longer  than  from  ten 


Fig.  17. — This  skiagraph,  taken  by  Ream,  shows  the  resorption  of  the  deciduous 
molar  roots,  due  to  the  eruption  of  the  permanent  bicuspids.  In  this  case  the  pulps 
of  the  deciduous  molars  were  vital. 

to  sixteen  hours  and  then  only  a  small  amount  should  be  employed. 
When  the  pulp  is  thus  poisoned,  formocresol  should  be  used  to  com- 
plete the  devitalization.  After  the  pulp  is  removed,  all  that  is  nec- 
essary to  fill  the  root  is  to  flood  with  chloroform  and  eucapercha  com- 
pound, and  fill  the  entire  cavity  with  gutta-percha.  It  is  supposed 
by  some  dentists  that  resorption  of  the  roots  does  not  take  place  when 
the  pulp  is  destroyed.  This  supposition  is  wrong.  The  root  may  not 
be  destroyed  as  readily  as  though  the  pulps  were  alive,  but  that 
resorption  does  take  place  has  been  clinically  demonstrated  in  the 
author's  practice.     Hunt,  of  Indianapolis,  was  of  the  opinion  that 


334  PEACTICAL   DEXTAL    THERAPEUTICS 

the  process  here  involved  is  one  of  absorption  rather  than  resorption, 

and  that  the  loss  of  tooth-root  is  usually  due  to  the  advances  of 
the  permanent  teeth  (see  Fig.  17). 

ARSENICAL  POISONING 

It  may  be  well  to  re-consider  here  the  treatment  of  local  poisoning 
by  arsenic  trioxid.  However,  when  such  treatment  is  necessary,  it  is 
due  to  carelessness  on  the  part  of  the  dentist  or  the  patient,  or  both. 
It  is  never  necessary  to  tell  the  patient  what  drug  or  remedy  has  been 
used  in  the  treatment  of  teeth,  many  times  it  is  advisable  not  to  do 
so;  but  whenever  an  agent  as  destructive  as  arsenic  trioxid  is  sealed 
within  a  tooth,  the  patient  should  be  thoroughly  impressed  with  the 
importance  of  keeping  an  appointment,  and  of  returning  before  the 
appointed  time  should  any  untoward  symptoms  develop.  The  patient 
should  also  be  informed  that  the  teeth  thus  treated  might  ache  for  a 
few  hours,  as  they  sometimes  do,  even  when  cocain  is  a  constituent  of 
the  arsenical  preparation;  but  that  the  aching  will  be  of  short 
duration.  In  case,  however,  the  tooth  or  gum  becomes  sore,  they 
should  be  instructed  to  return  at  once. 

In  those  cases  where  the  arsenical  preparation  is  not  hermetically 
sealed  within  the  tooth  and  some  of  it  gets  on  the  gum  tissue,  remain- 
ing only  long  enough  to  cause  devitalization,  all  that  is  necessary  is  to 
first  wash  the  part  with  an  antiseptic  solution,  and  then  mechanically 
pick  off  the  dead  or  sloughed  tissue  with  sterile  pliers  until  bleeding  is 
produced,  if  this  is  possible,  after  which  the  part  should  be  disinfected 
and  the  tissue  stimulated.  To  disinfect  the  part,  any  good  disinfect- 
ant can  be  used.  Nothing  is  better  here  than  the  official  3  per  cent, 
solution  of  hydrogen  dioxid.  As  a  means  of  stimulating  the  cells, 
iodin  compounds  are  useful.  The  official  compound  solution  of  iodin 
(5  per  cent.)  can  be  applied  by  first  drying  the  part.  After  removing 
the  dead  tissue  and  disinfecting,  the  author  prefers  applying  the 
euroform  paste  on  cotton  or  gauze.  A  prescription  should  also  be 
written  for  an  antiseptic  mouth-wash  with  which  the  patient  should 
keep  the  mouth  as  clean  as  possible.  The  treatment  can  be  repeated 
as  often  as  the  case  necessitates;  usually  one  or  two  treatments  will 
suffice. 

In  those  severe  cases  where  the  arsenic  trioxid  has  penetrated  to, 
and  devitalized  the  process  as  well  as  the  gum,  the  first  treatment  is 
surgical.  After  washing  with  an  antiseptic  solution,  the  affected  proc- 
ess should  be  removed  with  a  suitable  bur  in  the  engine.  It  may  be 
necessary  in  extensive  cases  to  extract  the  tooth,  after  which  the 
treatment  is  practically  the  same  as  has  been  outlined  above  (see 


REMOVAL    or   VITAL   PULPS    AND    SUBSEQUENT    TREATMENT      335 

Fig.  15,  p.  326).  Sometimes  there  is  pain  following  the  surgical 
removal  of  the  affected  process.  In  this  case  the  euroform  paste  is 
especially  indicated;  the  orthoform  controls  the  pain,  the  europhen 
disinfects  and  stimulates,  and  the  liquid  petroleum  keeps  the  saliva, 
laden  with  bacteria,  out  of  the  wound.  The  case  should  be  watched 
closely  and  the  stimulating  treatment  kept  up  until  the  part  has 
healed.  The  tissue  in  the  interproximal  space  will  never  be  fully 
reproduced,  and  will  always  be  a  source  of  more  or  less  iannoyance. 

It  will  be  noted  that  in  discussing  the  treatment  of  local  arsenical 
poisoning,  no  mention  has  been  made  of  dialysed  iron.  The  practice 
of  applying  this  agent  to  the  affected  part  is  both  useless  and  wrong. 

In  conclusion,  the  author  desires  to  emphasize,  what  was  stated  in 
the  beginning,  that  it  is  the  plain  duty  of  every  practitioner  to  save 
the  pulps  of  teeth  in  all  cases  where  it  can  be  done  with  any  reasonable 
degree  of  success;  yet  experience  and  observation  will  soon  show  the 
folly  of  attempting  to  save  a  pulp  that  is  in  a  state  of  passive  hyper- 
emia or  true  inflammation,  and  will  prove  also  that  in  these  cases 
the  safest  practice  is  to  remove  the  pulp  and  subsequently  fill  the 
canals,  notwithstanding  the  difficulty  often  attending  the  performace 
of  this  operation.  It  behooves  us,  therefore,  to  study  carefully  the 
pathology  of  the  dental  pulp,  that  we  may  be  able  to  diagnose  the 
condition  correctly  and  apply  our  therapeutics  accordingly. 


DIAGNOSIS  AND  TREATMENT  OF  PIItPLESS  TEETH  AND 
THEIR  SEQUELS;  INCLUDING  THE  PREPARA- 
TION OF  THE  CANALS  FOR  FILLING 

GENERAL  CONSIDERATIONS 

The  treatment  of  pulpless  teeth  with  gangrenous  pulps  and  their 
sequelae  has  in  the  past,  to  a  great  extent,  been  purely  empirical. 
The  reason  for  this  can  be  found  in  the  apparent  lack  of  interest  which 
generally  has  been  shown  in  the  chemistry  of  pulp  decomposition. 
A  knowledge  of  the  changes  wrought  in  the  splitting  up  of  the  com- 
plex bodies  of  the  dental  pulp  by  microorganisms  is  of  vital  interest 
to  every  practising  dentist;  and  every  student  should,  therefore, 
familiarize  himself  with  this  important  subject.  The  only  method  by 
which  drugs  and  remedies  can  be  scientifically  applied  to  the  treat- 
ment of  the  condition  under  consideration  is  to  have  a  definite  knowl- 
edge of  the  intermediate  and  end-products  resulting  from  the  putre- 
factive process. 

Every  practitioner  of  dentistry  knows  from  sad  past  experience 
that  in  the  process  of  pulp  decomposition  some  kinds  of  mephitic 
gases  are  evolved  which,  if  confined,  would  produce  severe  pathologic 
disturbances;  but  just  what  the  gases  were  and  how  the  unfavorable 
conditions  were  brought  about  we  were  left  to  conjecture.  From  our 
study  of  the  chemistry  of  pulp  decomposition  we  have  every  reason 
for  believing  that  the  main  gases  produced  Sive  ammonia  and  hydrogen 
sulphid.  When  these  gases  are  generated  and  cannot  readily  escape 
through  a  cavity,  pressure  is  produced,  thereby  forcing  the  infectious 
material  through  the  apices  of  the  roots  into  the  surrounding  tissues 
from  which  infection,  septic  pericementitis  and,  in  many  instances, 
an  alveolar  abscess  result. 

Coagulating  Drugs. — There  has  been  much  discussion  in  the 
dental  literature  of  the  past  in  regard  to  the  penetrating  or  non- 
penetrating power  of  coagulating  agents  in  gangrenous  root-canals. 
It  is  true,  as  claimed  by  some  authorities,  that  such  drugs  as  phenol, 
creosote,  solutions  of  zinc  chlorid,  etc.,  are  contraindicated  in  the 
treatment  of  gangrenous  pulps,  but  not  because  they  possess  the 
coagulating  property;  for  when  the  dental  pulp  is  undergoing  or  has 
undergone  the  process  of  decomposition,  the  proteid  constituents,  or 
coagulable  substances,  have  lost  their  former  identity,  and  new  com- 

336 


DIAGNOSIS   AND   TREATMENT   OF   PULPLESS   TEETH  337 

pounds,  with  entirely  different  properties,  have  been  formed.  In 
selecting  drugs  to  be  used  in  the  treatment  of  this  condition,  the 
author  will  therefore  eliminate  the  question  of  coagulation,  and  will 
select  drugs  which,  if  properly  used,  will  unite  chemically  with  the 
intermediate  and  end-products  of  decomposition,  converting  them 
into  odorless  and  non -infectious  compounds,  as  well  as  destroy  germ 
life. 

Important  Products  of  Pulp  Decomposition. — In  this  connection 
it  should  be  remembered  that  the  gangrenous  condition  has  been 
brought  about  through  the  agency  of  microorganisms  by  a  gradual 
analytic  process,  and  among  the  products  formed  which  must  be  con- 
sidered in  the  treatment  are  hydrogen  sulphid,  poisonous  ptomains  or 
toxins,  and  ammonia  or  derivatives,  the  latter  gas  being  evolved  from 
the  further  putrefaction  of  the  intermediate  compounds  (ptomains 
and  amido  acids).  It  is  well  to  remember  also  that/a/^  or  fatty  acids 
are  a  class  of  end-products  resulting  from  the  putrefaction  of  proteid 
substances. 

The  main  gases  formed,  then,  are  ammonia  and  hydrogen  sulphid. 
Now  it  will  be  necessary  to  dispose  of  these  gases  by  our  initial  treat- 
ment in  order  to  hermetically  seal  the  cavity,  an  object  the  accom- 
plishment of  which  is  much  desired  in  the  treatment  of  these  cases; 
for  by  so  doing  we  prevent  the  oral  fluids  from  contaminating  the 
medicine  within  the  tooth,  the  medicine  from  escaping  into  the 
patient's  mouth,  and  the  tooth  from  changing  color  during  the  time 
of  treatment. 

Drugs  Indicated. — It  has  been  shown  by  Cassidy  and  others  that 
formaldehyd  (CH2O)  is  a  valuable  therapeutic  agent  if  properly  used. 
This  gas  occurs  in  commerce  in  a  37  per  cent,  aqueous  solution,  which 
solution  is  recognized  by  the  United  States  Pharmacopeia  under  the 
name  of  liquor  formaldehyd,  or  formalin.  The  gas  will  unite  with 
ammonia,  producing  uro tropin,  a  solid,  as  6CH2O  -f  4NH3  =  (CH2)6- 
N4  +  6H2O. 

Formaldehyd  unites  also  with  hydrogen  sulphid,  forming,  in  the 
author's  opinion,  methyl  alcohol,  a  liquid,  and  sulphur,  a  solid,  as 
2CH2O  +  2H2S  =  2CH3OH  +  S2. 

It  is  stated  on  good  authority  that  this  same  gas,  formaldehyd, 
unites  with  basic  ptomains,  forming  inodorous  compounds.  By  the 
use  of  formaldehyd,  then,  in  our  initial  treatment  for  a  gangrenous 
pulp,  the  irritating  gases  and  poisonous  liquids  (largely  ptomains) 
can  be  changed  chemically  into  nonirritating  and  nonpoisonous  liquids 
and  solids.  The  official  solution  of  formaldehyd,  however,  is  too 
irritating  for  general  use;  therefore,  inasmuch  as  fats  result  from  pulp 


338  PRACTICAL   DENTAL   THERAPEUTICS 

decomposition  and  are  present  as  such  in  a  gangrenous  root-canal,  the 
author,  several  years  ago,  selected  cresol  as  an  agent  with  which  to 
dilute  the  ofiicial  solution  and  thereby  modify  the  irritating  action 
of  formaldehyd.  Cresol  is  also  recognized  by  the  United  States 
Pharmacopeia  under  this  name.  Formerly  the  product  was  commer- 
cially called  tricresol.  This  agent  has  a  tendency  to  darken  when 
exposed  to  light.  It  is  recommended  that  a  clear  solution  be  obtained 
and  then  kept  in  an  amber-colored  bottle. 

Liquor  formaldehyd  can  be  diluted  with  such  other  agents  as 
phenol,  or  creosote,  if,  in  the  latter  instance,  a  small  amount  of 
alcohol  is  added  to  clear  the  solution.  Cresol,  however,  is  recom- 
mended for  four  principal  reasons: 

1.  It  is  miscible  with  the  liquor  formaldehyd  in  all  proportions, 
thus  making,  without  the  addition  of  alcohol,  a  good  pharmacal 
product  from  which  formaldehyd  gas  is  constantly  generated. 

2.  It  is  a  good  disinfectant — much  more  powerful  than  phenol. 

3.  It  possesses  an  anodyne  property  which  modifies  the  irritating 
action  of  formaldehyd. 

4.  It  acts  chemically  upon  fatty  compounds,  thereby  disposing 
to  advantage  of  these  substances. 

Factors  to  be  Considered. — In  the  successful  treatment  of  the 
conditions  under  consideration,  there  are  three  important  purposes 
to  be  accomplished: 

1.  Establish  asepsis. 

2.  Prevent  recurring  sepsis. 

3.  Preserve  or  restore  the  color  of  the  tooth. 

In  calUng  the  attention  of  the  reader  to  a  method  of  treating  this 
condition,  which  has  proved  very  successful  in  the  author's  practice, 
I  desire  to  emphasize  the  necessity  of  observing  the  details  of  the 
method.  The  successful  management  of  pulpless  teeth  is  largely 
a  matter  of  chemistry,  and  the  treatment  involves  the  use  of  certain 
chemical  agents.  In  view  of  our  present  knowledge  of  focal  infection 
and  its  relation  to  systemic  disease,  the  author  considers  the  treat- 
ment of  pulpless  teeth  one  of  the  most  important  subjects  before  our 
profession  to-day. 

Diagnosis  of  Dead  Pulps. — It  is  not  a  difficult  matter,  as  a  rule, 
to  differentiate  between  teeth  containing  Hving  or  dead  pulps.  The 
cUnical  history,  the  color  of  the  tooth,  its  response  or  nonresponse  to 
thermal  or  electrical  stimuli,  will  lead  us  to  suspect  that  the  pulp  is 
dead  or  aUve.  Now  we  are  ready  to  confirm  our  diagnosis.  One  of 
the  best  means  of  confirming  the  diagnosis  of  a  dead  pulp  is  the  use  of 
electricity  by  an  instrument  known  as  the  "vibrating  coil."     This 


Dental  caries. 


Saprophytic  bacteria. 


Mephitic  gases. 
(NH3-H2S.) 


Water. 


Fatty  products. 


Fig.   18. 


DIAGNOSIS   AND    TREATMENT    OF   PULPLESS   TEETH  339 

consists  of  a  single  dry  cell  and  a  vibrating  coil  with  a  switch  to 
control  the  current.  The  cord  leading  from  the  positive  pole  is 
arranged  with  a  holder  so  that  a  broach  may  be  attached ;  cotton  is 
wrapped  around  the  broach  and  moistened  when  it  is  applied  to 
the  suspected  tooth.  The  cord  from  the  negative  pole  is  attached 
to  a  metal  holder,  which  is  held  by  the  hand  of  the  patient;  thus 
the  circuit  is  completed.  A  stronger  current  may  be  had  by 
moving  the  positive  pole  to  the  right  on  the  instrument  or  by 
gradually  withdrawing  the  cylinder  which  runs  through  the  coil. 
One  should  always  start  with  a  weak  current,  gradually  increasing 
the  strength  if  no  response  is  obtained.  It  is  best  to  apply  the 
current  first  to  a  tooth  known  to  be  vital,  and  use  this  as  a  control 
or  guide.  When  two  approximating  teeth  contain  metal  fillings, 
the  current  should  be  applied  to  the  tooth  so  as  not  to  come  in  con- 
tact with  the  filling;  otherwise  the  current  may  be  conducted  to 
the  filHng  of  the  adjoining  tooth,  which,  if  vital,  would  respond, 
leading  one  to  believe  that  the  tooth  to  which  the  current  is  ap- 
plied is  vital,  when,  as  a  matter  of  fact,  it  may  be  pulpless. 

After  the  diagnosis  of  a  dead  pulp  has  been  confirmed,  the  pulp 
chamber  is  freely  opened  with  a  suitable  round  bur.  It  is  not 
enough  here  to  simply  determine  whether  the  pulp  is  dead  or  alive ; 
but,  if  dead,  an  effort  should  be  made  to  determine  whether  the  con- 
dition is  one  of  true  gangrene  with  its  characteristic  odoriferous  and 
gaseous  end-products  or  whether,  as  sometimes  occurs,  the  active 
pyogenic  microorganisms  have  Hquefied  a  part  or  all  of  the  bulbous 
portion  of  the  pulp,  forming  drops  of  pus  in  the  pulp  chamber  with 
practically  no  odor,  and  with  the  tissue  in  the  canals  still  vital. 

Treatment  of  Pulpless  Teeth. — When  a  patient  presents  with  a 
pulpless  tooth,  the  original  pulp  tissue  is  generally  either  in  a  moist 
gangrenous  condition,  as  a  result  of  the  action  of  bacteria  (Fig.  i8) 
or  a  previous  attempt  has  been  made  to  remove  the  pulp  and  fill 
the  canals.  (See  History  of  Cases,  p.  351.)  In  either  case,  the  first 
treatment  here,  in  my  opinion,  should  be  a  dressing  of  formocresol. 

I^ — Cresolis, 

Liquoris  formaldehydi,        aa  f 3j  (4.0  mUs). — M. 
Sig. — Use  as  directed. 

Other  preparations  may  be  just  as  effective;  but  this  is  the  one  I 
have  used  for  years  and  about  which  I  can  speak  with  assurance. 
Under  aseptic  precautions,  this  remedy  should  be  placed  in  the  pulp 
chamber  only,  and  the  dressing  retained  with  cement.     This  dressing 


340  PRACTICAL   DENTAL   THERAPEUTICS 

should  remain  at  least  twenty-four  hours,  and  in  the  interim  a  radio- 
graph of  the  tooth  and  periapical  area  should  be  obtained. 

The  chemical  action  of  formocresol  on  a  gangrenous  pulp  has  been 
published  so  often  and  is  now  so  well  known  that  I  need  not  repeat 
it  here.^  I  know  that  many  good  men  to-day  advocate  the  immedi- 
ate cleansing  of  a  gangrenous  canal;  but  I  am  firmly  of  the  belief  that 
the  safest  and  best  practice  is  to  first  supply  at  -least  one  dressing  of 
formocresol.  Gilmer,  Moody,  and  others,  have  found  that  the  pre- 
dominating organism  in  the  conditions  resulting  from  a  gangrenous 
pulp,  therefore  the  group  active  in  bringing  about  the  decomposition, 
is  a  streptococcus,  "with  graded  variations  from  a  hemolytic  strep- 
tococcus with  a  wide  zone  of  hemolysis  in  the  acute  abscess  to  a 
streptococcus  viridans  in  the  chronic."  One  initial  treatment  of  for- 
mocresol in  these  cases,  while  it  may  not  kill  all  of  the  organisms 
present,  will  certainly  lessen  the  number  and  lower  the  virulency  of 
those  remaining.  Surely  no  one  will  deny  the  favorable  and  valuable 
effect  of  formaldehyd  gas  on  the  intermediate  and  end-products  of 
pulp  decomposition.  With  these  poisonous  and  irritating  products 
chemically  neutralized;  with  the  bacteria,  inaugurating  the  process, 
killed  or  their  virulency  lowered,  we  may  the  more  safely,  I  believe, 
work  to  the  root-end,  and  clean  and  enlarge  the  canal  by  a  chemico- 
mechanical  process.  By  this  I  mean  the  use  of  chemicals  in  connec- 
tion with  broaches,  reamers,  files,  and  other  necessary  instruments. 

At  the  present  time,  so  far  as  I  know,  there  are  three  chemical 
agents  in  general  use  for  this  purpose — metallic  potassium  and  sodium, 
as  advocated  by  Rhein;  sulphuric  acid  by  Callahan;  and  phenolsul- 
phonic  acid  by  the  author.  We  will  now  consider  the  chemistry  and 
pharmacology  of  these  agents. 

Potassium  and  Sodium  (K  and  Na) . — This  is  an  alloy  composed 
of  a  mixture  of  the  two  metals.  It  occurs  as  a  semi-solid,  silvery- 
white  preparation.  Like  the  metals  of  which  it  is  composed,  it  must 
be  kept  under  a  hydrocarbon  oil  or  paraffin  to  protect  it  from  the  air 
and  moisture.  It  was  first  introduced  in  the  United  States  by 
Schreier,  of  Vienna,  in  1893,  ^t  the  World's  Columbian  Dental  Con- 
gress in  Chicago.  So  far  as  I  am  able  to  learn,  Schreier  has  never 
pubHshed  the  proportion  of  the  metals  in  his  product.  The  metals 
will  produce  an  alloy  in  varying  proportions ;  and,  in  my  opinion,  the 
more  sodium  in  the  mixture  the  better  the  preparation  will  be  as  long 
as  there  is  enough  potassium  to  make  an  alloy  when  the  two  metals 
are  properly  mixed.     No  attempt  should  ever  be  made  to  mix  the 

^  The  chemistry  of  pulp  decomposition  has  been  discussed  by  the  author  in  Johnson's 
Text-book  of  Operative  Dentistry,"  p.  341,  and  in  various  dental  journals. 


DIAGNOSIS   AND    TREATMENT   OF   PULPLESS    TEETH  341 

metals  unless  they  are  constantly  kept  under  a  hydrocarbon  oil,  such 
as  kerosene,  gasoline  or  benzene;  and,  even  then,  it  is  best  to  leave  the 
compounding  to  an  experienced  chemist  or  pharmacist. 

Technic  of  Using  Schreier's  Alloy. — Schreier's  preparation  comes 
in  a  small  glass  tube,  one  end  of  which  is  open  so  that  the  alloy  may 
be  covered  with  paraffin,  which  prevents  undue  exposure  to  air  or 
moisture.  It  is  to  the  advocacy  of  Rhein  that  the  preparation  owes 
its  popularity  in  this  country.  He  has  developed  a  technic  which,  if 
followed  carefully,  insures  success.  With  the  rubber  dam  adjusted 
and  everything  in  readiness,  a  barbed  broach  may  be  pushed  through 
the  paraffin  cover  and  into  the  metallic  mass ;  on  gently  withdrawing 
it  small  particles  adhere  to  the  broach.  It  is  best  to  have  these 
particles  as  near  the  end  of  the  broach  as  possible,  in  which  manner 
the  alloy  is  transferred  to  the  canal.  It  is  presumed  that  the  canal 
is  moist,  which  is  generally  the  case.  A  violent  reaction  at  once 
takes  place,  the  metals  attack  the  water  molecule  and  hydroxids  are 
formed,  liberating  hydrogen  gas.  If  potassium  predominates  in  the 
alloy,  or  even  if  it  is  present  in  equal  proportion  with  the  sodium, 
a  sufficient  amount  of  heat  is  generated  by  the  reaction  to  cause  the 
liberated  hydrogen  to  burn.  To  set  the  hydrogen  off  actively  and 
start  it  burning  requires  a  temperature  of  from  500°  to  6oo°C.  This 
burning  of  the  hydrogen  is  an  objection,  in  my  opinion,  and  it  was  for 
this  reason  that  I  suggested  (above)  the  employment  of  an  alloy  with 
sodium  predominating.  After  the  initial  reaction  and  the  hydroxids 
are  formed,  they  in  turn  act  upon  the  fatty  end-products,  in  case  of  a 
gangrenous  pulp,  forming  a  soluble  soap.  Where  the  organic  tissue 
has  not  been  decomposed  by  bacteria  the  action  of  the  hydroxids 
differs  somewhat  in  that  the  hydroxyl  ion  unites  with  the  protein 
constituent  of  the  tissue,  forming  a  soluble  alkaline  albuminate.  In 
either  case,  it  will  be  observed,  the  product  formed  is  soluble,  and  may 
be  washed  out  of  the  canal,  leaving  it  clean  and  sterile. 

The  action  of  potassium  and  sodium  hydroxid  on  the  contents 
of  a  canal  of  a  tooth,  whether  or  not  the  tissue  is  decomposed,  is  the 
same.  When  the  salts  and  compounds  of  these  metals  are  internally 
administered  their  action  differs  only  in  that  the  potassium  ion  is 
more  depressant  than  the  sodium  ion  in  its  influence  upon  the  cardiac, 
muscular  and  nervous  systems.  But  in  the  canal  of  a  tooth  we  do 
not  have  this  pharmacologic  effect  of  the  metal  ion ;  here  we  get  only 
that  which  is  desired — the  chemical  action  of  the  hydroxyl  ion. 

Rationale  of  Rhein's  Method. — With  this  information  before  us, 
let  us  examine  the  rationale  of  Rhein's  method  of  using  metallic 
potassium  and  sodium  in  the  treatment  and  preparation  of  canals 


342  PRACTICAL   DENTAL   THERAPEUTICS 

for  filling.  The  chemistry  is  correct;  a  description  of  the  method 
reads  well.  The  question  is  whether  the  preparation  is  safe  and 
practical.  My  reply  is  that  it  is  safe  in  the  hands  of  those  who  will 
master  the  technic  and  use  it  with  intelligence  and  care;  but  that  it  is 
not  as  practical  as  other  chemicals  which  may  be  used  with  equally 
good  results.  It  must  be  remembered  that  each  particle  of  alloy 
that  is  introduced  into  a  canal  is  decomposed  just  as  soon  as  it 
comes  in  contact  with  moisture.  This  practically  means  that  the 
initial  reaction  between  the  metals  and  water  takes  place  at  the 
mouth  of  the  canal;  for  it  is  difficult  to  keep  the  canal  free  from  mois- 
ture down  to  the  place  at  which  we  stop  each  succeeding  time  we 
enter  it  with  the  broach  or  other  instrument.  The  mere  withdrawal 
of  the  latter  would  necessarily  moisten  the  canal,  more  or  less,  which 
had  been  affected  by  the  remedy.  Then,  too,  if  we  are  using  an 
alloy,  like  Schreier's,  in  which  there  is  enough  potassium  to  cause 
the  Uberated  hydrogen  to  burn,  as  a  result  of  the  intense  heat  from 
the  violent  reaction  between  the  metals  and  water,  we  are  constantly 
moistening  the  canal;  for  when  hydrogen  burns  it  does  so  by  virtue 
of  the  oxygen  in  the  air  supporting  the  combustion,  and  water  (H2O) 
is  chemically  formed.  Therefore,  it  is  impossible  to  keep  the  canal 
free  from  moisture  when  we  use  an  alloy  which  reacts  on  water  with 
such  violence  that  the  heat  generated  causes  the  hydrogen  to  burn. 
Even  Rhein  himself,  with  all  his  experience,  technic  and  care,  wisely 
cautions  against  the  possibiHty  of  destroying,  or  affecting  deleteri- 
ously, 'the  tooth  structure  at  the  mouth  of  the  canal  by  this  "burn- 
ing" process.  Does  this  not  mean,  then,  that  unless  extreme  care 
is  taken  to  prevent  the  initial  reaction  until  the  alloy  is  down  in 
the  canal  to  the  point  desired,  the  chemicals  which  actually  do  the 
work  down  in  the  canal  proper  are  the  hydroxids  of  the  metals? 
If  this  be  true,  why  should  we  not  introduce  into  the  canal  and  use 
one  of  these  hydroxids  (there  is  absolutely  no  advantage  in  using 
both)  from  the  beginning?  When  I  want  the  action  of  these  alkalies 
in  a  canal,  I  generally  use,  after  the  method  of  Pruyn,  of  Chicago, 
a  saturated  solution  of  sodium  hydroxid  (NaOH).  This  is  a  rather 
thick,  syrupy  solution,  which  may  be  applied  like  any  solution  of  its 
kind. 

There  is  another  objection  to  the  use  of  metallic  potassium  and 
sodium,  especially  a  mixture  of  the  metals  in  which  potassium  pre- 
dominates or  is  present  in  equal  proportion.  Granting  that  with 
proper  care  one  could  keep  moisture  from  the  canal  as  he  gradually 
approached  the  end  in  the  use  of  the  alloy,  I  am  one  of  those  who 
firmly  believe  that  we  should  not  burn  our  way  through  the  live, 


DIAGNOSIS   AND    TREATMENT   OF   PULPLESS    TEETH  343 

healthy  cementum  at  the  end  of  the  root  from  which  a  live  pulp 
has  been  removed.  One  of  the  first  things  a  student  learns  in  study- 
ing chemistry  is  "that  hydrogen  burns  with  the  hottest  known 
flame."  With  a  dental  granuloma  or  alveolar  abscess  in  the  peri- 
apical region,  it  is  a  different  proposition;  but,  even  here,  we  may 
accomplish  our  purpose  with  far  less  destructive  chemicals. 

This  brings  us  to  a  discussion  of  the  use  of  "acids"  instead  of 
"alkalies"  for  the  purpose  under  consideration.  The  acids  which 
I  shall  discuss  are  sulphuric  acid  (30  per  cent.)  and  phenolsulphonic 
acid  (80  per  cent.). 

Advantages  of  Phenolsulphonic  Acid. — The  chemical  action  of 
sulphuric  and  phenolsulphonic  acids  for  the  use  under  consideration 
is  practically  the  same;  and  they  will  be  discussed  here  conjointly. 
Personally,  I  prefer  phenolsulphonic  acid.  Its  consistency  is  thick 
and  syrupy  in  the  80  per  cent,  strength  which  is  recommended ;  thus 
a  drop  will  adhere  to  the  end  of  a  broach  or  other  applicator,  per- 
mitting it  to  be  carried  even  into  the  canals  of  upper  teeth  without 
difficulty.  The  acid  does  not  materially  affect  a  broach,  and  if  any 
of  it  accidentally  gets  on  the  enamel  of  the  crown  of  the  tooth  and 
is  not  noticed  for  a  time,  it  does  not  decalcify  and  whiten  the  spot 
to  the  extent  that  sulphuric  acid  would  do.  When  the  acid  is 
worked  through  the  end  of  the  root,  as  is  desirable  for  cauterization  in 
cases  of  a  dental  granuloma  or  alveolar  abscess,  it  is  sufficiently 
cauterant  for  the  purposes  desired,  yet  not  as  destructive  as  sulphuric 
acid  would  be;  and,  owing  to  its  analgesic  tendencies,  causes  less 
pericementitis.  In  this  connection,  however,  I  want  to  say  that 
we  should  not  expect  to  do  this  work  as  it  must  be  done,  without 
more  or  less  soreness  following  the  treatment.  There  is  a  wide 
variance  in  patients  regarding  the  reaction  of  the  periapical  tissues 
to  these  agents:  and  in  these  chronic  conditions  it  is  generally  best 
to  invite  and  create  inflammatory  reaction  that  the  sluggish  cells 
in  the  area  may  take  on  new  Hfe  and  activity.  This  should  not 
be  done,  however,  at  the  expense  of  unnecessary  destruction  of 
tissue. 

It  might  be  supposed  by  those  who  have  not  used  phenol- 
sulphonic acid  that,  possessing  the  above-mentioned  advantages  over 
plain  sulphuric  acid,  it  would  be  less  effective  in  the  canal.  I  have 
not  found  this  to  be  the  case.  The  agent  has  one  possible  disad- 
vantage. In  using  either  of  these  acids,  after  they  have  been  intro- 
duced into  the  canal  for  a  time  and  the  walls  thereof  filled  with  a 
suitable  broach,  they  should  be  neutraHzed  with  a  solution  of 
sodium  bicarbonate  (NaHCOs).     In  the  case  of  sulphuric  acid  the 


344 


PRACTICAL   DENTAL   THERAPEUTICS 


salt  formed  as  a  result  of  the  reaction  is  sodium  sulphate  (Na2S04), 
a  freely  soluble  salt.  With  phenolsulphonic  acid  the  salt  formed  is 
sodium  phenolsulphonate  (NaSO3.C6H4.OH  +  2H2O),  which  is  not 
as  soluble  as  sodium  sulphate.  I  can  conceive  how  it  might  be  pos- 
sible in  a  very  fine  canal  to  temporarily  block  it  with  the  salt  formed. 
An  excess  of  water  would  readily  dissolve  the  salt  or  by  using  a 
solution  of  sodium  bicarbonate  of  not  more  than  10  per  cent,  strength 
the  salt  would  be  dissolved  as  soon  as  formed  by  the  reaction. 
This  is  a  thing  which  probably  would  never  occur  in  practice;  but  I 
mention  it  as  a  possible  disadvantage. 

Caution  in  Using  Callahan's  Method. — In  using  sulphuric  acid 
Callahan  advises  that  it  be  a  30  per  cent,  solution.  In  this  strength 
there  is  not  the  danger  of  charring  or  carbonizing  the  pulp  tissue 
which  may  be  in  the  canal  undecomposed,  that  there  would  be  if  a 
more  concentrated  solution  were  used.  Sulphuric  acid  is  one  of  the 
most  corrosive  acids.  When  applied  to  the  skin,  accidently  or  other- 
wise, in  concentrated  form,  it  causes  an  intense,  burning  pain,  and 
results  in  a  rapid  destruction  of  tissue.  The  eschar  is  at  first  white, 
gradually  becoming  brown,  and  causes  a  coal-black  slough.  The 
corrosive  effect  upon  mucous  membranes  or  the  tissue  in  the  peri- 
apical area  of  teeth  is  still  more  marked  than  upon  the  skin.  The 
acid  rapidly  abstracts  water  from  the  tissue,  the  alkahes  are  neu- 
tralized and  the  proteins  precipitated,  which  results  in  complete 
destruction  of  the  tissue.  This  carbonizing  of  the  undecomposed 
tissue  in  the  canal  should  be  avoided,  as  it  forms  a  mechanical  ob- 
struction difficult  to  remove;  and  it  is  for  this  reason  that  the  30 
per  cent,  solution  is  recommended  by  Callahan. 

Technic  of  Using  Acid  'Method. — We  will  now  consider  the 
technic  of  treating  pulpless  teeth  and  preparing  the  canals  for  fill- 
ing by  the  "acid  method."  I  take  it  to  be  thoroughly  understood 
that  good  root-canal  work  means  the  use  of  the  rubber  dam  in  all 
cases,  and  the  strict  observance  of  asepsis.  With  me  at  this  time, 
as  heretofore,  it  means  asepsis  fortified  by  antiseptic  precautions. 
I  make  this  statement  because  it  is  so  difficult  to  observe  strict 
asepsis  in  our  dental  offices. 

In  a  large  percentage  of  cases  of  gangrenous  pulps  or  imper- 
fectly filled  canals,  the  radiograph  will  disclose  a  dark  and  suspicious 
area  at  the  end  of  the  root.  With  this  evidence,  and  under  the  con- 
ditions, we  may  properly  diagnose  the  case  as  a  dental  granuloma 
or  alveolar  abscess.  This  growth  may  be  nonpurulent  or  of  the  pus- 
discharging  variety.  It  is  only  recently  that  these  nonpurulent 
growths — true  dental  granulomas — have  been  recognized  as  such; 


DIAGNOSIS   AND    TREATMENT    OF   PULPLESS    TEETH  345 

and  the  treatment  of  such  conditions  in  the  past  has  not  been  as 
specifically  emphasized  as  their  significance  merits. 

Nonpiirulent  Variety. — It  makes  no  difference  with  me  whether 
this  growth  is  associated  with  a  tooth,  the  canal  of  which  contains  a 
gangrenous  pulp,  per  se,  or  an  imperfect  root-canal  filling — the  treat- 
ment is  practically  the  same.  At  the  first  sitting,  when  the  diagnosis 
is  made  by  the  aid  of  a  radiograph,  or  even  before  the  latter  is  ob- 
tained, under  aseptic  precautions,  the  pulp  chamber  is  opened  into 
freely  and  a  dressing  of  formocresol  is  hermetically  sealed  in  for  two 
or  three  days.  Cement  should  always  be  used  here  to  retain  the 
dressing.  This  treatment  is  for  the  purpose  of  neutralizing  the  gan- 
grenous contents  of  the  canal,  or,  in  a  measure,  sterilizing  the  old 
root  filling,  as  the  case  may  be.  In  making  an  attempt  to  work  one's 
way  by  chemico-mechanical  means  to  and  through  the  root-end  with- 
out the  previous  apphcation  of  some  strong  disinfectant,  like  formo- 
cresol, I  have  found  that  acute  symptoms  too  frequently  develop. 
This  initial  formocresol  treatment  prevents  many  of  the  acute 
symptoms  which  follow  the  immediate  attempt  to  reach  the  root-end, 
however  careful  one  may  be.  At  the  second  sitting,  I  want  the  radio- 
graph; then  with  the  rubber  dam  always  in  place  and  all  necessary 
instruments  steriHzed,  I  carefully  work  to  the  apex  with  phenol- 
sulphonic  acid,  using  in  connection  therewith  fine,  smooth,  twist 
and  file  broaches.  This  is  what  I  call  the  chemico-mechanical  proc- 
ess. The  acid  is  frequently  neutralized  with  a  solution  of  sodium 
bicarbonate;  and  since  phenolsulphonic  acid  is  the  chemical  I  am 
using,  for  reasons  previously  mentioned  I  prefer  not  to  have  the 
alkaline  solution  more  than  lo  per  cent,  in  strength.  If  sulphuric 
acid  is  the  agent  used,  this  point  is  not  so  essential.  The  sodium 
bicarbonate  solution  not  only  chemically  neutralizes  the  acid,  but 
the  effervescence  caused  by  the  reaction  aids  materially  in  removing 
the  "mushy"  and  disintegrated  material  from  the  canal.  After  I 
am  satisfied  that  I  am  at  the  end  of  the  root,  that  the  acid  is  neutral- 
ized and  the  canal  perfectly  clean  and  sufficiently  enlarged,  then,  if 
the  radiograph  has  indicated  a  periapical  involvement,  with  the  acid 
and  a  smaU  stiff  broach,  I  work  my  way  through  into  the  affected 
area.  Some  of  the  acid  is  purposely  worked  through  the  end  for  the 
express  purpose  of  destroying  the  growth  by  cauterization.  In  the 
first  edition  of  this  book  (1909),  I  spoke  of  phenolsulphonic  acid  as  a 
stimulating  cauterant  and  called  it  a  "bone  cell  stimulant;"  and 
after  seven  years  of  further  use  of  the  agent  in  these  conditions,  I 
am  stiU  of  this  opinion.  Personally,  I  have  obtained  better  results 
by  using  phenolsulphonic  acid  than  any  other  cauterant  at  my  com- 


346  PRACTICAL   DENTAL   THERAPEUTICS 

mand.  When  I  am  through  the  root-end,  the  acid  in  the  canal — not 
that  which  has  passed  through — is  neutraHzed  with  the  sodium  bicar- 
bonate solution,  the  canal  desiccated  with  modified  alcohol  (70  per 
cent,  alcohol  to  which  i  gr.  of  thymol  is  added  to  the  fluid  ounce), 
and  a  dressing  of  eucalyptol  compound  (very  Uttle  of  the  remedy  on 
the  cotton)  is  sealed  in  the  canal.  This  remedy  is  used  here  because 
it  is  a  stimulating  antiseptic,  thus  fortifying  asepsis  with  antiseptics; 
but,  as  elsewhere  mentioned,  it  also  aids  in  hermetically  sealing  the 
canal  which  is  done  at  this  time  by  using  a  combination  of  a  good 
grade  of  temporary  stopping  and  cement.  The  heated  stopping  is 
placed  immediately  over  the  eucalyptol  compound  dressing  and  it 
adheres  firmly  to  the  walls  of  the  cavity;  the  excess  is  removed  and 
the  remaining  portion  of  the  cavity  filled  with  cement.  This  dress- 
ing is  left  for  a  period  of  from  four  days  to  a  week,  when,  if  the  case 
has  progressed  nicely  and  pericementitis  is  absent,  the  canals  are 
filled. 

What  becomes  of  the  growth  and  tissues  that  were  cauterized 
in  the  periapical  region,  I  frankly  admit  I  do  not  know;  neither  does 
anyone  else.  Nature  here,  as  in  many  other  instances,  has  not  re- 
vealed her  secret;  but  I  do  know  that  it  is  disposed  of  in  some  way, 
for  under  the  above  treatment  bone  and  soft  tissue  regeneration  is 
effected  (see  History  of  Cases  with  Illustrations,  p.  356).  When,  in 
all  therapeutics,  we  learn  to  work  with  and  not  against  Nature,  we 
will  have  taken  a  long  step  forward.  If,  in  these  cases,  the  root- 
end  can  be  put  and  kept  in  such  condition  that  the  surrounding  tis- 
sues can  lie  in  physiologic  contact  with  it,  regeneration  is  effected;  if 
this  biologic  condition  cannot  be  brought  about,  all  medication  fails 
and  surgery  is  the  only  road  to  success. 

Removing  Old  Root-filling. — In  those  cases  where  a  previous 
attempt  had  been  made  to  fill  the  canal  with  gutta-percha,  it  is  nec- 
essary, after  the  initial  formocresol  treatment,  to  first  remove  the 
old  root-filling.  Generally  in  these  cases  there  is  only  one  cone  in 
each  canal,  in  which  event  the  acid  will  soon  work  its  way  around  the 
cone  when  it  may  be  loosened  with  a  suitable  instrument  and  re- 
moved in  one  piece.  However,  occasionally  it  becomes  necessary 
to  remove  a  filHng  where  the  gutta-percha  has  been  fijmly  packed  in 
the  canal.  Here  the  use  of  xylol,  or  xylene,  as  it  is  also  called,  will 
aid  materially  in  disintegrating  the  gutta-percha.  This  is  dimethyl- 
benzene  (C6H4(CH3)2),  and  while  the  agent  does  not  dissolve  the 
gutta-percha  in  the  sense  that  chloroform  would,  it  readily  attacks 
and  disintegrates  the  material,  making  its  removal,  after  a  few  min- 
utes, comparatively  easy.     My  attention  was  called  to  this  agent 


DIAGNOSIS    AND    TREATMENT    OF    PULPLESS    TEETH  347 

by  Best,  of  Minneapolis;  but  I  think  he  credits  another  with  its 
introduction.     It  may  be  procured  from  any  pharmacy. 

Removing  Blockade  in  Canal. — We  should  never  use  any  drug  or 
chemical  bhndly.  Therefore,  if  in  working  up  or  down  a  canal,  we 
find  it  blocked  and  are  unable  to  reach  the  end,  instead  of  going  on 
blindly  using  only  one  chemical,  whatever  it  may  be,  and  running 
the  risk  of  making  a  false  pocket,  we  should  stop  and  ascertain,  if 
possible,  and  it  is  generally  possible,  the  nature  and  character  of  the 
material  causing  the  blockade.  It  may  be  a  remnant  of  an  old  gutta- 
percha cone;  it  may  be  pulp  tissue  undecomposed  which  has  been 
inadvertently  packed  in  the  canal;  it  may  be  some  inorganic  material, 
such  as  a  pulp  nodule,  secondary  dentin,  or  other  loosened  inorganic 
material  which  has  been  pushed  into  the  canal.  If  we  have 
reasons  for  concluding  that  an  old  gutta-percha  filhng  is  caus- 
ing the  blockade,  xylol  is  the  chemical  to  use;  if  we  think  it  is  organic 
tissue,  the  alkalies,  Hke  potassium  and  sodium  or  a  strong  solution  of 
one  of  the  hydroxids  of  these  metals,  is  indicated;  if  an  inorganic 
material,  sulphuric  acid  or  phenolsulphonic  acid  will  best  answer  our 
purpose.  My  plea  is  not  to  become  wedded  to  any  one  chemical 
or  method.  Be  eclectic  and  take  the  necessary  time  to  do  this  work 
carefully  and  well.     It  is  the  most  important  work  you  have  to  do. 

Purulent  Variety. — The  treatment  of  an  alveolar  abscess  of  the  pur- 
ulent or  discharging  variety  is  practically  the  same  as  previously  out- 
lined, except  that  in  these  cases  there  is  not  the  danger  of  acute  symp- 
toms arising;  therefore,  one  may  safely,  under  aseptic  precautions, 
work  to  and  through  the  root-ends  without  the  initial  formocresol 
treatment.  However,  even  here  I  beheve  it  is  the  best  practice  to 
use  formocresol  first;  but  it  is  not  so  essential  as  in  the  case  of  non- 
purulent growths.  After  we  are  through  the  end  of  the  root,  it  is 
best  to  first  force  a  physiologic  salt  solution  through  the  sinus,  and 
if  no  sinus  is  present  it  is  generally  best  to  establish  an  opening 
through  the  overlying  soft  tissue  and  process,  then  cauterize  the 
track  with  some  stimulating  cauterant.  Here,  I  also  use  phenolsul- 
phonic acid,  fuU  strength,  as  was  used  above  for  reasons  mentioned. 
After  this  my  treatment  is  the  same  as  previously  given  for  a  dental 
granuloma. 

Ionization. — Some  of  my  readers  may  be  surprised  that  I  could 
discuss  at  this  time  the  treatment  of  dental  granulomas  or  alveolar 
abscesses  without  the  mention  of  the  so-called  ionization  method. 
The  intimation  has  gone  out  from  dift'erent  sources  that  unless  ioni- 
zation is  employed  in  the  treatment  of  these  conditions,  a  cure  will 
not  be  effected.     I  want  to  brand  any  such  intimation  as  being 


348  PILICTICAL   DENTAL    THERAPEUTICS 

absolutely  erroneous.  There  are  many  chemic  agents  which  act  as 
cauterants  and  which  may  be  relied  upon  to  eradicate  "this  patho- 
logic growth  at  the  end  of  the  root."  ]\Iuch,  of  course,  will  depend 
upon  the  extent  of  the  destruction  of  the  pericemental  membrane 
and  the  consequent  amount  of  denuded  root-end  as  a  result  of  the 
granulomatous  growth.  As  stated  above,  for  years  I  have  advocated 
and  used  phenolsulphonic  acid  for  both  the  nonpurulent  and  pus- 
discharging  varieties;  and  I  desire  to  state  that  I  have  been  curing 
these  conditions.  I  do  not  msh  to  imply  that  phenolsulphonic  acid 
is  the  only  agent  that  will  accompHsh  favorable  results;  but  it  is  the 
one  I  have  successfully  used.  What  a  dismal  old  world  this  would 
be  if  there  were  only  one  royal  road  to  success  in  any  line  of  human 
endeavor!  I  do  not  object  to  anyone  using  so-called  ionization.  I 
know  results  may  be  obtained  by  the  proper  use  of  the  method;  but 
I  do  object  strenuously  to  the  opinion  which  is  prevalent  in  some 
quarters  that  those  who  are  not  using  this  method  are  failing  to  cure 
their  cases. 

Ionic  Theory. — Now  let  us  discuss  the  ionic  theory  from  the 
chemic  and  pharmacologic  viewpoint.  Ionization  in  chemistry 
means  the  act  of  dissociating  the  ions  of  a  salt  or  compound  by 
passing  it  in  solution  or  by  means  of  the  electric  current.  The  men 
who  have  been  attempting  to  cure,  and  I  want  to  say  that  in  many 
instances  they  do  cure,  dental  granulomas  or  alveolar  abscesses  by 
dissociating  the  ions  of  certain  salts — notably  zinc  chlorid,  with  the 
electric  current — have  been  taught  by  Rhein,  the  most  ardent 
advocate  of  the  method  in  the  United  States,  that  results  are  obtained 
by  virtue  of  the  infected  tissues  in  the  area  being  sterilized  by  the  so- 
called  ionization.  Price,  of  Cleveland,  takes  issue  with  Rhein  on  this 
point;  and  states  that  he  had  aspirated  in  many  cases  after  using  the 
current  by  Rhein's  method  and  that  he  was  able  in  nearly  every 
instance  to  make  a  culture  from  the  germs  thus  obtained  from  the 
area  supposed  to  have  been  sterihzed.  The  aspiration  was  done 
immediately  after  the  current  and  salt  solution  were  employed.  This 
does  not  prove  that  we  cannot  cure  these  conditions  by  this  method 
of  treatment.  Rhein  and  others  have  proved  conclusively  that  such 
conditions  can  be  so  cured;  but  it  does  prove  that  the  results  are  not 
obtained  by  complete  steriHzation  as  claimed.  Price  further  makes 
the  statement  that  ionization  as  such  cannot  be  accomplished  in  the 
manner  explained  by  Rhein;  and  Price  is  of  the  opinion  that  what  is 
really  done  by  the  current  in  these  cases  is  cauterization  oj  the  affected 
area.  The  point  I  wish  to  make  is  this:  If  cauterization  of  the 
tissues  involved  will  effect  a  cure  in  dental  granulomas  or  alveolar 


DIAGNOSIS   AND    TREATMENT    OF   PULPLESS    TEETH  349 

abscesses,  as  I  and  many  others  know  it  will,  the  proposition  resolves 
itself  into  the  question:  What  is  the  most  practical  and  effectual 
means  of  bringing  about  this  result?  It  is  simply  a  question  which 
each  one  must  decide  for  himself;  and  each  should  use  those  agents 
and  methods  which  in  his  hands  offer  the  greatest  opportunity  for ' 
success.  It  is  wrong  for  any  man,  especially  one  who  is  looked  upon 
as  an  authority,  to  claim  that  there  is  only  one  method  or  means 
of  accomplishing  definite  results,  and  that  that  method  is  the  one 
which  he  champions,  and  perhaps  has  originated.  It  is  wrong  be- 
cause it  is  not  true;  and,  not  being  true,  it  is  discouraging  to  the 
thousands  of  men  in  the  profession  who  are  anxious  to  do  honest, 
conscientious  root-canal  work,  but  who  are  absolutely  at  a  loss  at 
this  time  as  to  just  how  good  work  may  be  done.  We  need  here, 
as  in  all  lines  of  dental  practice,  a  standard  on  which  we  may  all  agree. 

In  recent  years  much  has  been  written  about  the  health-value  of 
removing  focal  infection.  This  is  all  important,  but  I  wish  to 
state,  with  all  the  emphasis  at  my  command,  that  the  majority  by 
far  of  teeth  thus  involved  may  be  therapeutically  or  surgically 
treated  so  that  they  will  not  be  a  menace  to  the  health  of  the  indi- 
vidual. Physicians  and  dentists  should  work  together  and  in 
harmony  on  this  proposition.  The  former  should  not  advise  the 
extraction  of  teeth  without  first  consulting  the  latter.  When  focal 
infection  is  found  or  suspected  in  the  mouth  by  the  medical  practi- 
tioner, his  plain  duty  lies  in  referring  the  patient  back  to  the  family 
dentist  with  such  suggestions  as  he  may  deem  advisable  in  the  case ; 
and  the  dentist's  duty  lies  in  removing  the  focus  of  infection  by  treat- 
ment or  extraction.  The  members  of  the  two  professions  should 
work  together  harmoniously  for  the  benefit  of  the  patient's  health, 
which  is  being  done  to-day. 

COMPLICATIONS.— Occasionally  we  encounter  complications 
in  the  treatment  of  pulpless  teeth.     These  will  now  be  considered. 

Badly  Decayed  Root. — Formocresol  is  very  destructive  to  the 
soft  tissues  of  the  mouth,  therefore  the  importance  of  always  adjust- 
ing the  rubber  dam.  If  this  cannot  be  done  on  account  of  a  badly 
decayed  root,  it  is  suggested  that  care  be  taken  in  seahng  the  remedy 
in  the  cavity  at  the  first  sitting,  and,  in  placing  the  cement,  the 
original  outHne  of  the  root  can  be  approximated.  After  the  cement 
has  set,  a  band  or  matrix  of  gold  or  German  silver  can  be  fitted  to, 
and  cemented  to  the  root.  In  doing  this  it  is  best  to  use  a  cement  of 
different  color  from  that  employed  for  treatment  purposes;  and  in 
treating  the  case  where  there  is  a  tooth  posterior,  it  is  best  to  place  a 
clamp  on  this  tooth,  gently  stretch  the  rubber  over  the  band  and 


35©  PRACTICAL   DENTAL   THERAPEUTICS 

thereby  avoid  loosening  it.  With  the  complication  thus  removed, 
the  treatment  is  the  same  as  previously  given. 

Pulp  Partially  Alive. — In  those  cases  where  the  pulp  tissue 
is  gangrenous  in  one  or  more  canals  of  a  multirooted  tooth  and  alive 
in  the  other  one  or  two  canals,  as  the  case  may  be,  we  will  find  much 
satisfaction  in  using  the  formocresol  remedy  (Fig.  19).  These 
are  exceptional  cases  and  it  is  difficult  to  know  whether  this  condition 
exists  until  the  second  sitting.  If  there  be  much  vitality  in  the  live 
pulp  tissue,  the  formaldehyd  in  the  remedy  will  doubtless  make 
the  tooth  ache,  but  after  we  know  the  conditions  our  method  of 
procedure  is  simple,  and  the  results  will  be  certain.  A  small  pledget 
of  cotton  dipped  in  the  remedy  can  gently  be  placed  over  the  mouths 
of  the  canals  which  contain  putrescent  material,  and  a  thin  quick- 
setting  cement  flowed  over  the  cotton.  After  the  cement  has  set, 
the  live  pulp  tissue  in  the  remaining  canals  can  be  anesthetized  or 
devitalized,  as  the  operator  deems  best  at  the  time.  These  remnants 
of  pulps  may  generally  be  desensitized  and  removed  with  very  little 
pain  by  gently  working  phenolsulphonic  acid  up  or  down  the  canal 
with  a  fine  broach.  Formerly  these  were  difficult  cases  to  treat, 
but  with  a  remedy  which  can  be  hermetically  sealed  in  a  gangrenous 
root-canal,  the  procedure  is  materially  simpHfied. 

Pulpal  Abscess. — It  was  previously  mentioned  that  one  may 
occasionally  open  into  a  suspected  tooth,  having  all  the  symptoms  of 
a  dead  pulp,  and  find  a  drop  of  pus  in  the  bulbous  portion  of  the 
pulp  with  the  remaining  portion  still  aHve.  Some  writers  call  this 
condition  a  septic  pulp  or  pulpal  abscess  in  contradistinction  to  gan- 
grene or  true  putrescence  (presence  of  gases).  In  such  a  case,  any 
remedy  containing  formaldehyd  may  cause  the  tooth  to  ache;  there- 
fore, this  must  be  taken  into  consideration,  and  in  the  treatment 
of  so-called  septic  pulps,  the  pus  should  be  washed  out  of  the  cavity 
with  a  warm  antiseptic  solution,  the  cavity  dried,  and  asepsis  estab- 
lished by  hermetically  sealing  in  a  much  smaller  amount  of  formo- 
cresol than  that  generally  used  in  cases  of  true  gangrene.  If  this 
precaution  is  taken  the  tooth  will  not  ache  long,  even  in  cases  where 
no  odor  is  present  and  the  vital  tissue  is  still  quite  sensitive.  This 
remedy  will  sterilize  the  tissue,  after  which,  at  the  second  sitting, 
the  pulp  can  be  anesthetized  or  devitalized  as  usual. 

Dry  Gangrene. — Sometimes  on  opening  into  a  pulpless  tooth 
we  find  the  canal  dry  and  odorless.  This  condition  is  called  dry 
gangrene  of  the  pulp.  It  is  not  really  a  complication  if  we  recognize 
that  microorganisms  may  be  present  and  seal  a  disinfectant  in  the 
canal  for  at  least  twenty-four  hours.     One  treatment  of  formocresol 


DIAGNOSIS   AND    TREATMENT    OF   PULPLESS    TEETH  35 1 

or  phenol  compound  will  correct  any  possible  trouble,  when  we  are 
ready  to  use  phenolsulphonic  acid,  after  which  the  canal  can  be  filled. 
The  author  realizes  that  the  method  of  treating  pulpless  teeth, 
here  given,  is  a  radical  departure  from  those  generally  used  in  the 
past.  With  the  knowledge  we  have  to-day  of  the  dire  results  of 
focal  infection;  and  with  the  X-ray  showing  that  the  root-ends  of 
pulpless  teeth  in  so  many  instances  are  foci  of  infection,  it  becomes 
necessary  to  either  improve  our  treatment  or  extract  these  teeth. 
The  following  cases  from  the  author's  practice,  treated  after  the 
methods  here  advocated,  speak  for  themselves. 

HISTORY  AND  TREATMENT  OF  PRACTICAL  CASES 

Series  No.   i. 

Patient. — Female.  Age,  about  33  years;  of  a  nervous  tempera- 
ment, and  not  in  good  physical  condition.  Had  suffered  more  or 
less  from  neuralgia.  All  teeth  extremely  h3^ersensitive.  Picture 
for  Fig.  20  was  taken  February  2,  1916. 

Treatment. — The  excementosed  second  bicuspid  was  extracted 
February  21.  (Fig.  21.)  The  porcelain  crown  was  removed  from 
the  first  bicuspid  on  February  28th,  and  formocresol  sealed  in 
canals.  On  March  ist  the  canals  were  cleansed  and  opened  with 
xylol  and  phenolsulphonic  acid,  when  diagnostic  wires  were  placed 
in  canals  and  picture  for  Fig.  22  taken.  The  canals  were  filled  on 
March  6th,  when  pictures  for  Fig.  23  and  Fig.  24,  showing  two 
views  of  root-filling,  were  taken. 

Series  No.  2  {a  and  h). 

Paitent. — Female.  Age,  about  32  years.  Presented  in  March, 
1916,  suffering  with  intermittent,  radiatmg  pains  in  the  back  of 
her  head  and  both  sides  of  her  neck.  The  general  condition  of  the 
patient  was  good,  except  that  she  was  rather  depressed  from  over- 
work. She  had  had  several  radiographs  taken  the  preceding  Sep- 
tember. A  nonpurulent  dental  granuloma  was  disclosed  on  the 
lower  second  bicuspid  on  either  side.  Fig.  25  of  this  series  shows 
the  granuloma  on  the  lower  right  bicuspid. 

Treatment. — {a)  Removed  porcelain  crown  on  March  ist  and 
sealed  formocresol  in  the  canal.  On  March  3,  the  canal  was 
cleaned  and  opened  with  xylol  and  phenolsulphonic  acid  and 
eucalyptol  compound  sealed  in.  The  canal  was  filled  on  March  8, 
when  picture  for  Fig.  26  was  taken.     The  tooth  was  giving  no  local 


352  PRACTICAL   DENTAL   THERAPEUTICS 

trouble,  apparently,  when  treatment  was  begun;  nor  was  any  sore- 
ness manifested  throughout  the  treatment.  Picture  for  Fig.  27  was 
taken  July  11,  about  4  months  after  the  canal  was  filled.  Picture 
for  Fig.  28  was  taken  September  25,  about  6^  months  after  root- 
filling  operation,  (b)  Picture  for  Fig.  29  of  this  series  shows  the 
granuloma  on  the  lower  left  bicuspid.  As  was  mentioned  of  the 
tooth  on  the  opposite  side  of  the  mouth,  this  tooth  also  was  giving  no 
apparent  local  trouble  when  treatment  was  begun.  The  gold  crown 
was  removed  on  March  4  and  I  immediately  worked  to  the  end 
of  the  root  with  xylol  and  phenolsulphonic  acid.  Sealed  eucalyptol 
compound  in  the  canal.  Patient  returned  March  8,  giving  history 
of  acute  apical  pericementitis,  which  was  still  in  evidence. 
Placed  diagnostic  wire  in  the  canal  with  formocresol  dressing,  when 
picture  for  Fig.  30  was  taken.  On  March  14  the  soreness  had  entirely 
subsided,  when  canal  was  filled.  This  case  illustrates  the  value  of 
the  initial  formocresol  dressing,  which  you  will  notice  was  not  used 
here.  Picture  for  Fig.  31  was  taken  July  11,  about  4  months  after 
root-filling  operation.  In  the  meantime  the  lower  left  first  molar, 
carrying  a  gold  inlay  which  restored  nearly  the  occlusal  third  of  the 
crown,  became  uncomfortable,  though  the  radiating  pains  in  the 
back  of  head  and  neck  had  completely  disappeared.  Fig.  31  shows 
the  diagnostic  wires  after  devitalizing  and  removing,  by  the  aid  of 
phenolsulphonic  acid,  an  almost  completely  calcified  pulp.  Picture 
for  Fig.  32  was  taken  September  25,  about  63^^  months  after  root- 
filling  operation  on  bicuspid,  and  2  months  after  that  on  the  molar. 

Series  No.  3. 

Patient. — Male.  Age,  about  40  years.  Nervous,  not  in  good 
physical  condition.  An  upper  right  first  molar  had  been  treated 
and  filled  about  3  months  previous  to  the  time  patient  was  re- 
ferred. Complained  that  his  tooth  "  had  never  felt  right  since  it 
had  been  treated."  Picture  for  Fig.  33  was  taken  May  26,  1916, 
before  I  saw  the  patient. 

Treatment. — On  June  10,  the  amalgam  filHng  was  removed,  as  was 
also  the  old  root-filling,  using  xylol  and  phenolsulphonic  acid.  The 
lingual  canal  seemed  blocked  and  a  false  pocket* had  been  made.  The 
canal  proper  appeared  to  be  blocked  with  undecomposed  pulp 
tissue.  I  used  a  saturated  solution  of  sodium  hydroxid  and .  in  5 
minutes'  time,  with  a  small  twist  broach,  the  end  of  the  root  was 
reached.  The  alkali  was  then  neutralized  with  phenolsulphonic 
acid.  Time  consumed  for  entire  operation  at  this  sitting — one 
hour.     I  mention  this  here  simply  to  show  that  if  we  go  at  these 


Series  No.  i. 


Fig.  20. 


Fig.  21. 


Fig.  22. 


Fig.  23. 


Fig.  24. 


Series  No.  2.     (a) 


Fig.  2;. 


Fig.  26. 


Fig.  27. 


Fig.  2i 


Series  No.  2.     (b) 


Fig.  29. 


Fig.  30. 


Fig.  31. 


Fig.  32. 


Series  No.  3. 


Fig.  33. 


Fig.  34. 


Fig.  35. 


Series  No.  4, 


Fig.  36. 


Fig.  37. 


Fig.  38. 


Series  No.  5. 


Fig.  39. 


Fig.  40. 


Fig.  41. 


Series  No.  6. 


Fig.  42. 


Fig.  43. 


Fig.  44. 


Series  No.  7. 


Fig.  45. 


Fig.  46. 


DIAGNOSIS   AND    TREATMENT   OF    PULPLESS    TEETH  353 

cases  in  an  intelligent  manner,  it  does  not  require  as  much  time  as 
some  operators  have  led  us  to  believe.  The  diagnostic  wires  were 
also  put  in  at  this  sitting  with  a  dressing  of  eucalyptol  compound, 
when  picture  for  Fig.  34  was  taken.  This  picture  shows  that  the  wire 
in  the  mesio-lingual  canal  was  not  in  as  far  as  the  canal  had  been 
explored,  or  else,  as  proved  to  be  the  case,  the  canal  was  not  properly 
opened.  Patient  returned  June  16.  Thinking  undecomposed  pulp 
tissue  also  blocked  the  mesio-lingual  canal,  the  saturated  solu- 
tion of  sodium  hydroxid  was  used.  In  3  minutes'  time  the  end  of 
the  root  was  reached.  The  alkali  was  neutrahzed  with  phenolsul- 
phonic  acid,  canals  desiccated  and  filled.  Ordered  radiograph 
for  Fig.  35.  The  patient  called  when  he  was  in  the  city,  late  in 
September,  and  reported  tooth  entirely  comfortable. 

Series  No.  4. 

Patient. — Female.  Age,  about  45  years.  Physical  condition 
very  good.  Presented  May  5,  191 6.  No  pain  or  discomfort  of  any 
kind;  but  she  had  noticed  a  discharging  sinus  in  the  region  of  the 
apex  of  the  upper  left  second  bicuspid.  So  far  as  patient  knew,  the 
abscess  had  been  standing  for  about  2  years.  Ordered  radiograph 
for  Fig.  36. 

Treatment. — Opened  into  the  pulp  chamber  on  the  above  date 
(May  5)  and  cleaned  canal  with  phenolsulphonic  acid,  working 
the  same  through  end  of  root  and  sinus,  after  using  physiologic 
salt  solution.  As  there  was  a  bad  odor,  formocresol  was  sealed  in 
the  canal.  On  May  8  the  canals  were  filled  and  picture  for 
Fig.  37  was  taken.     Picture  for  Fig.  38  was  taken  January  4,  1917. 

Series  No.  5. 

Patient. — Male.  Age,  about  55  years.  Blood-pressure  abnorm- 
ally high,  and  occasionally  had  spells  of  dizziness.  Two  involved 
teeth  were  extracted  and  upper  lateral  treatment  was  given  as  follows 
for  gangrenous  pulp. 

Treatment. — On  May  31,  1916,  the  canal  was  exposed  and  a 
dressing  of  formocresol  sealed  in.  The  patient  could  not  return 
until  June  29,  when  the  canal  was  cleaned  and  enlarged  with 
phenolsulphonic  acid,  and  unexpectedly  an  abscess  sa,c  was  ruptured 
and  pus,  thick  and  yellow,  with  streaks  of  blood,  flowed  freely  from 
the  canal.  The  discharge  was  checked,  the  acid  worked  through 
the  end  and  formocresol  sealed  in  the  canal.  On  this  date  (June 
29)  picture  for  Fig.  39  was  taken.  Patient  did  not  return,  owing  to 
absence  from  city,  until  July  20,  when  the  root-filUng  was  inserted. 

23 


354     .  PRACTICAL   DENTAL   THERAPEUTICS 

Picture  for  Fig.  40  was  taken  September  9,  about  7  weeks  after 
root-filling  operation  and  about  9  weeks  after  the  pus  was  noticed. 
Picture  for  Fig.  41  was  taken  December  30,  1916.  This  case  illus- 
trates the  advantage  of  the  radiograph  in  the  treatment  of  all  cases 
of  pulpless  teeth.  Notice  how  the  fluid  gutta-percha  escapes 
through  the  multiple  foramina. 

Series  No.  6 

Patient. — Male.  Age,  about  38  years.  The  vital  teeth  in  picture 
for  Fig.  42  had  carried  an  inlay  bridge  for  several  years.  Decay  had 
progressed  under  the  molar  inlay,  and  when  patient  presented  the 
pulp  of  this  tooth  was  highly  congested  and  aching  severely. 

Treatment. — On  Sept.  5,  1916,  when  I  first  saw  the  patient,  the 
pulp  was  caused  to  bleed  and  phenol  compound  sealed  in  the  cavity. 
On  Sept.  7  the  patient  returned  giving  history  of  the  tooth  being 
comfortable.  At  this  time  the  bridge  was  removed  and  devitalizing 
fiber  appHed.  On  account  of  my  leaving  the  city  and  the  patient 
being  a  dentist,  the  arsenical  dressing  was  left  for  one  week,  with 
instructions  to  remove  the  same  in  case  the  tooth  manifested  sore- 
ness. This  was  not  necessary  and  the  patient  returned  on  Sept. 
14.  Contrary  to  my  usual  custom  of  using  formocresol  after  a  pulp 
has  been  poisoned  with  arsenic  trioxid,  I  removed  the  pulp  at  this 
sitting  and  cleaned  the  canals  with  phenolsulphonic  acid.  Eucalyp- 
tol  compound  was  then  sealed  in,  and  on  Sept.  18  the  canals  were 
filled.     Picture  for  Fig.  43  was  taken  Oct.  5. 

In  Fig.  44  we  find  a  good  illustration  of  the  care  that  should 
be  taken  in  the  interpretation  of  dental  radiographs.  There  is 
shown  a  dental  granuloma  on  the  mesial  root  of  the  lower  molar,  as 
was  subsequently  verified  by  treatment;  but  the  point  to  which  I 
desire  to  call  especial  attention  is  the  dark  line  parallel  with  the  distal 
root.  This  might  be  mistaken  for  a  gutta-percha  point  passing 
through  a  punctured  root.  Closer  examination  will  show  that  some- 
thing on  the  film,  having  no  relation  to  the  tooth,  produced  the 
shadow,  for  the  line  curves  upward  and  may  be  noticed  distal  to  the 
gold  crown.  Radiographs  are  a  great  aid  in  dental  diagnosis,  but 
they  are  by  no  means  positive. 

Series  No.  7 

Patient. — Female.  Age,  11  years.  While  playing  at  school,  ah 
accident  occurred  on  Oct.  20,  1916,  in  which  both  upper  central 
incisors  were  broken  off — one  exposing  the  pulp,  the  other  being 
nearly  exposed. 


DIAGNOSIS   AND    TREATMENT    OE   PULPLESS    TEETH  355 

Treatment. — The  pulp  in  the  left  central,  which,  was  exposed, 
was  carefully  anesthetized  by  pressure  anesthesia  and  removed  by 
the  family  dentist.  The  pulp  in  the  right  central  (not  quite  exposed) 
was  removed  under  nitrous  oxid-oxygen  anesthesia.  As  the  roots  were 
not  fully  formed  and  the  apices  were  large,  the  patient  was  referred 
for  the  root-filling  operation.  Picture  for  Fig.  45  was  taken  Oct.  21, 
after  both  pulps  had  been  removed.  On  Oct.  24,  both  canals  were 
cleaned  with  phenolsulphonic  acid  and  eucalyptol  compound  was 
sealed  in  with  double  sealing.  The  root-filling  operation  in  the  left 
central  was  done  on  Oct.  26;  in  the  right  central  on  Oct.  30,  when 
picture  for  Fig.  46  was  taken.  The  root-filling  was  covered  with 
zinc  oxychlorid  cement,  as  is  my  practice  where  it  may  be  done, 
and  the  patient  referred  back  to  the  family  dentist  with  the  sug- 
gestion that  porcelain  jacket  crowns  be  made  which  would  not 
disturb  the  root-fillings. 

The  following  two  cases  are  from  the  practice  of  Dr.  J.  F. 
Biddle,  Pittsburgh,  Pa. 

Series  No.  8 

Patient. — Female.  Age,  22.  Presented  with  a  badly  swollen 
upper  lip,  nose  and  surrounding  tissues.  The  tissues  were  so  dis- 
torted that  it  was  dif&cult  to  tell  where  the  lip  ended  and  the  nose 
began.  In  the  preceding  48  hours  she  had  had  chills  and  fever 
intermittently  and  her  temperature  at  this  sitting  was  1023^°. 

Treatment. — On  account  of  her  extreme  nervousness,  it  was  im- 
possible to  make  an  oral  examination  at  this  time;  hence,  nitrous 
oxid  and  oxygen  were  administered  and  the  soft  tissues  at  the  jimc- 
tion  of  the  Up  and  gum  were  lanced,  about  45  minims  of  a  thick  yellow- 
ish-green pus  being  removed,  after  which  the  cavity  was  irrigated 
with  physiologic  salt  solution  and  injected  with  10  minims  of  tinc- 
ture of  iodin.  The  patient  was  instructed  to  take  a  dose  of  Epsom 
salts  and  to  keep  an  ice  bag  over  the  affected  part.  The  following 
day  her  condition  was  much  improved,  temperature  99^°,  and 
upon  reopening  the  wound  about  30  minims  of  pus  and  blood  were 
removed. 

Radiograph  for  Fig.  47  was  taken  which  shows  that,  of  the  four 
teeth  crowned,  none  of  their  roots  had  been  filled  and  all  were  ab- 
scessed. The  crowns  were  removed  and  a  treatment  of  formocresol 
was  sealed  in  the  canals.  On  the  third  day,  the  canals  were  opened 
to  the  apex  with  reamers,  aided  by  50  per  cent,  sulphuric  acid.  Upon 
going  through  canals  at  apex  of  roots  there  was  no  sensation,  hence 
wires  were  inserted,  and  a  second  radiograph  (Fig.  48)  taken,  to 


356  PRACTICAL   DENTAL   THERAPEUTICS 

determine  whether  all  canals  had  been  properly  opened.  The  worst 
condition  was  over  the  right  lateral  and  central  incisors,  and  as  it 
was  necessary  to  restore  a  healthy  condition  as  quickly  as  possible 
on  account  of  the  patient's  leaving  the  city,  50  per  cent,  sulphuric 
acid  was  forced  through  the  canals  of  these  two  teeth  and  out 
through  a  sinus  over  the  lateral  incisor.  This  was  followed  by 
4  ounces  of  physiologic  salt  solution  using  a  2-ounce  syringe  vnth  a 
fine  platinum  point  which  was  forced  into  the  canal,  while  the  sides 
were  packed  with  unvulcanized  rubber  to  prevent  the  return  of  the 
fluid. 

A  second  treatment  of  formocresol  was  sealed  in  the  four  teeth, 
and  allowed  to  remain  for  48  hours.  The  canals  were  then  enlarged 
and  a  third  treatment  of  formocresol  (modified)  was  sealed  in  for  24 
hours,  followed  by  a  treatment  of  oil  of  cloves  which  remained  for 
four  days.  The  canals  were  then  filled  and  a  temporary  plate  which 
had  been  made  when  the  crowns  were  removed  did  duty  for  six  months, 
after  which  the  third  radiograph  (Fig.  49)  was  taken.  Fearing 
lest  the  shadow  over  the  right  lateral  might  be  an  abscess  still  exist- 
ing over  this  tooth,  the  soft  tissues  were  injected  with  novocain 
and  a  small  bur  used  to  enter  the  bone  at  the  apex  of  the  root,  but 
it  was  found  to  be  in  normal  condition  and  a  specimen  taken  from 
this  location  was  found  to  be  negative.  The  fact  that  this  area  was 
not  as  dense  as  the  remainder  of  the  tract  is  evidently  due  to  the 
amount  of  bone  that  was  removed  in  enlarging  the  sinus  and  the 
area  at  the  apex. 

Four  years  ago  new  crowns  were  adjusted  to  these  teeth,  from 
which  time  they  have  given  the  patient  no  further  discomfort. 

Series  No.  9. 

Patient. — Male.  Age,  50.  Very  active — at  his  desk  greater  part 
of  the  day — conferences,  also  outside  interests — works  from  14  to 
16  hours  daily,  hearty  eater,  moderate  drinker.  Had  great  powers 
of  concentration  which  appeared  to  be  much  impaired  within  the 
last  year.  Examination  revealed  a  sKght  leaking  of  one  of  the  valves 
of  his  heart,  gastrointestinal  disturbances,  also  trace  of  albumin  in 
the  urine.  X-ray  examination  showed  a  number  of  unfilled  roots, 
misfit  crowns  and  pyorrhea  alveolaris. 

Treatment. — The  crowns  and  three  teeth  were  removed.  All 
other  partially  filled  or  gangrenous  canals  were  treated  and  filled 
and  the  gums  restored  to  a  healthy  condition.  One  tooth,  a  radio- 
graph of  which  I  shall  use  to  illustrate  the  regeneration  of  bone 


Series  No.  8. 


Fig.  47. 


Fig.  48. 


Fig.  49, 


Series  No.  9. 


Fig.  so. 


Fig.  si. 


DIAGNOSIS    AND    TREATMENT    OF    PULPLESS    TEETH  357 

around  the  apex,  was  considered  hopeless.  This  tooth  was  exceed- 
ingly loose  and  when  the  debris  was  removed  a  flow  of  pus  filled  the 
cavity.  The  pus  was  evacuated  as  thoroughly  as  possible  and  a 
specimen  was  sent  to  the  laboratory.  It  was  found  to  contain  strep- 
tococcus fecalis,  streptococcus  salivarius  and  streptococcus  viri- 
dans.  A  treatment  of  formocresol  was  sealed  in  the  pulp  chamber. 
After  48  hours  the  treatment  was  removed  and  the  canal  was  en- 
larged. Next  the  canal  was  cleaned  with  50  per  cent,  sulphuric  acid, 
and  a  second  treatment  of  formocresol  was  sealed  in  for  another  48 
hours,  after  which  a  treatment  of  oil  of  cloves  was  allowed  to  remain 
in  the  canal  for  a  week.  The  canal  was  flooded  with  eucalyptol 
which  displaced  the  air,  this  in  turn  being  displaced  by  chloro- 
percha,  followed  by  a  number  of  fine  gutta-percha  points,  packed 
until  the  mass  became  solid.  A  crown  with  very  Kttle  contour  was 
inserted,  which  was  used  as  an  attachment  for  a  clasp  on  a  plate. 

At  the  time  of  beginning  of  treatment  of  this  case,  radiograph 
for  Fig.  50  was  taken,  and  four  months  later  for  Fig.  51,  which  shows 
the  rarefied  area  at  the  apex  of  the  root  to  be  filling  in  with  bone  in  a 
very  gratifjdng  manner.  I  could  cite  many  other  cases  with  larger 
denuded  areas,  but  this  one  I  consider  one  of  the  most  hopeless  I 
ever  attempted  to  treat. 

Since  the  patient's  teeth  have  received  attention  and  his  mouth 
has  been  placed  in  hygienic  condition  his  health  has  greatly  improved. 
Whether  or  not  this  improvement  be  due  to  the  correction  of 
diseased  oral  conditions,  I  think  we  will  all  agree  that  abscessed 
teeth  should  receive  early  attention,  no  matter  how  or  where  we  may 
find  them. 


DIAGNOSIS  AXD  TREAT^IEXT  OF  NONSEPTIC 
PERICEMENTITIS 

GENERAL  CONSIDERATIONS 

It  is  not  the  intention  to  introduce  in  these  pages  needless  patho- 
logic facts,  yet  in  the  treatment  of  pericementitis  it  is  important  to 
remember  that  the  pericemental  membrane  is  very  vascular  and  well 
supplied  with  nen,-es;  that  it  is  enclosed  within  bony  walls,  and, 
therefore,  when  inflammation  exists  in  the  tissue  the  membrane 
becomes  thickened,  forcing  the  tooth  from  its  socket.  This  elonga- 
tion of  the  affected  tooth  is  one  of  the  chief  symptoms  of  true 
pericementitis. 

Before  discussing  the  therapeutics  of  this  condition,  I  desire  to 
indeHbly  impress  upon  the  mind  of  the  reader  the  fact  that  this  con- 
dition is  too  frequently  produced  by  carelessness  on  the  part  of  den- 
tists. It  is  not  always  possible  to  successfully  perform  dental  opera- 
tions without  irritating  the  susceptible  pericemental  membrane; 
however,  much  of  the  trouble  can  be  avoided  if  judgment  is  exercised 
and  proper  precautions  are  taken  in  treating  teeth. 

It  is  essential  that  we  differentiate  between  nonseptic  and  septic 
pericementitis.  Both  are  inflammatory  conditions  of  the  perice- 
mental membrane,  the  difference  being  due  largely  to  the  exciting 
agents  causing  the  pathologic  condition.  Nonseptic  pericementitis 
results  largely  from  drug  or  mechanical  irritants,  while  septic  perice- 
mentitis is  caused  by  pathogenic  bacteria  and  other  poisonous  and 
irritating  substances  which  have  escaped  from  septic  root-canals. 
Both  conditions  may  result  in  suppuration;  the  former  through  cryp- 
togenic or  hematogenous  infection  from  the  circulation,  the  latter 
as  the  natural  consequence  of  the  progress  of  the  disease.  I  shall 
discuss  here  the  treatment  of  nonseptic  pericementitis  only.  Those 
cases  resulting  in  pus  formation  or  alveolar  abscess  -^dll  be  con- 
sidered subsequently. 

There  are  at  least  two  classes  of  irritants  by  which  nonseptic 
pericementitis  is  produced,  \'iz. : 

1.  Drug  irritants. 

2.  Mechanical  irritants. 

Drug  Irritants. — There  are  many  circumstances  and  conditions 
which  influence  the  action  of  drugs  upon  dift'erent  individuals  and 


TREATMENT    OF   NONSEPTIC   PERICEMENTITIS  359 

upon  the  same  individual  under  different  conditions.  We  find  cases 
occasionally  where  pulps  have  been  removed  by  pressure  anesthesia, 
and  where,  seemingly  at  least,  every  precaution  was  taken  in  steriUz- 
ing  the  dentin,  selecting  a  sterile  anesthetizing  solution,  and  in 
applying  the  pressure,  yet  severe  apical  pericementitis  follows.  This 
may  or  may  not  be  due  to  the  drugs  used  in  performing  the  operation. 
There  are  cases,  too,  where  the  pericemental  membrane  becomes 
highly  inflamed  and  extremely  responsive  from  the  action  of  arsenic 
trioxid,  even  when  the  drug  was  properly  sealed  within  the  tooth  only 
a  short  time.  These  are  conditions  over  which  the  operator  seems 
to  have  no  control.  I  know  that  this  is  a  dangerous  doctrine  to 
promulgate;  for  it  is  so  easy  to  blame  the  patient  for  some  idiosyn- 
crasy, when  the  fault  is  ours.  Drugs  are  often  responsible  for  these 
conditions  by  having  been  injudiciously  employed;  yet  it  is  only 
fair  to  state  what  every  pharmacologist  knows  to  be  a  fact  that 
the  action  and  effect  of  drugs  are  modified  or  influenced  by  such 
conditions  as  disease,  temperament,  sex,  race,  size,  age,  habit,  idio- 
syncrasy and  temperature,  and  the  method,  time  of  administration, 
preparation  and  dose  of  the  drug.  It  has  been  stated  elsewhere  that 
anodyne  treatment  is  indicated  after  the  mechanical  or  surgical  re- 
moval of  the  pulp.  Therefore,  care  should  be  taken  to  select  drugs 
for  this  purpose  which  produce  a  soothing  and  not  an  irritating  effect. 
There  are  some  instances  in  dental  practice  where  we  desire  to  irritate 
and  thereby  stimulate  the  pericemental  membrane;  but  this  should 
be  avoided  here.  Judgment  should  also  be  exercised  in  sealing  in 
anodyne  remedies,  such  as  phenol,  oil  of  cloves,  etc.,  in  the  canals, 
especially  in  bicuspid  and  molar  teeth,  for  should  the  temporary 
filling  be  left  too  full  and  the  remedy  forced  through  the  apex  by  the 
closing  of  the  jaws,  even  these  agents  cease  to  be  anodynes  and  be- 
come irritants.  Whether  phenol,  oil  of  cloves,  and  similar  drugs  or 
remedies  are  anodynes  or  irritants,  depends  largely,  then,  on  where 
and  how  they  are  used. 

In  filling  root-canals  it  is  the  practice  of  many  dentists  to  moisten 
the  canals  with  eucalyptol  before  introducing  chloropercha  and  the 
gutta-percha  cone.  Care  must  be  taken  here  to  use  eucalyptol  and 
not  oil  of  eucalyptus,  unless  it  be  the  refined  product.  Commercial 
oil  of  eucalyptus  has  been  the  cause  of  many  cases  of  apical  perice- 
mentitis following  the  most  careful  filling  of  root-canals.  The 
eucalyptus  tree  produces  a  volatile  oil  which  contains  three  constitu- 
ents, each  distilHng  over  at  different  temperatures ;  the  first  product 
thus  obtained  is  eucalyptol,  hence  the  most  volatile  constituent  of 
oil  of  eucalyptus  and  the  one  which  is  the  solvent  for  gutta-percha. 


36o 


PRACTICAL   DENTAL   THERAPEUTICS 


While  eucalyptol  is  a  slight  irritant,  it  is  not  nearly  so  irritating  as 
oil  of  eucalyptus.  The  irritating  property  of  eucalyptol  can  be 
modified  and  its  antiseptic  value  increased  by  adding  menthol  and 
thymol  in  the  following  proportions. 


I^ — Mentholis, 
Thymolis, 
Eucalyptolis, 
Sig. — Use  as  directed. 


gr.  ij  (0.13  Gm.) 
gr.  iij  (0.18  Gm.) 
f5j  (4.0  mils) — M. 


This  remedy  is  equally  as  good  a  solvent  for  gutta-percha  as  is  euca- 
Ij^tol  alone,  and  will  be  called  eucalyptol  compound  in  the  following 
pages. 

Some  drugs  when  internally  administered,  notably  mercury  and 
its  compounds,  are  capable  of  producing  nonseptic  pericementitis. 
This  has  been  previously  mentioned  under  Mercurial  Stomatitis. 

Mechanical  Irritants. — The  pericemental  membrane  is  fre- 
quently, I  might  add  too  frequently,  irritated  by  mechanical  irritants, 
such  as  root-canal  fillings.  There  is,  perhaps,  more  pericementitis 
produced  by  root-canal  fillings  than  by  any  other  mechanical  irritant. 
In  filling  root-canals  we  should  be  absolutely  certain  that  the  canal 
is  aseptic.  If  there  be  any  doubt  as  to  this,  the  operation  should  be 
deferred.     The  technic  of  filling  root-canals  will  be  discussed  later. 


Fig.  52. 

There  are  many  other  mechanical  irritants  which  can  be  men- 
tioned as  causative  factors  in  producing  pericementitis;  suchjas 
ill-fitting  partial  plates,  crowns  and  bridges,  malleting,  regulating, 
faulty  occlusion,  calcific  deposits  on  the  roots  of  teeth,  impaction 
of  f 0 od  betv/een  teeth  with  faulty  or  no  contacts,  etc.  (Fig.  52.)  This 
patient  presented  with  a  case  of  severe  pericementitis.  Not  having 
treated  the  tooth  myself,  the  picture  was  taken  to  ascertain  the 
condition  of  the  canals  of  the  second  molar.  It  shows  that  the  mesial 
canals  were  small  and  tortuous  and  not  filled  to  the  end.  This 
might  have  caused  the  pericemental  trouble;  but,  at  the  time,  I 


TREATMENT    OF   NONSEPTIC   PERICEMENTITIS  36 1 

questioned  it  very  much.  You  will  also  notice  that  a  pulp  nodule 
shows  distinctly  in  the  third  molar.  This  was  verified  by  a  second 
radiograph.  As  yet  the  nodule  is  causing  no  trouble.  The  occlu- 
sion on  the  inlay  was  a  little  too  full  and  there  was  a  slight  tendency 
toward  a  pyorrheal  pocket  on  the  distal,  due  to  the  tooth  tipping 
forward  owing  to  the  loss  of  the  first  molar  and  the  occlusion — 
thus  opening  the  contact  slightly.  Here  we  had  four  possible  causes 
for  the  pericementitis:  The  nodule  in  the  third  molar,  the  faulty 
contact  and  the  resultant  impaction  of  food  between  the  molars, 
the  occlusion,  and  the  imperfectly  filled  root-canals  of  the  second 
molar.  The  adjustment  of  the  occlusion  and  the  scaling  and  polish- 
ing of  the  exposed  tooth-surface  cured  the  case.  This  was  done 
three  years  ago  and  there  has  been  no  recurrence  of  the  trouble. 

Treatment  of  Nonseptic  Pericementitis.— ^The  first  step  in  the 
treatment  of  nonseptic  pericementitis  is  to  adopt  the  surgical  prin- 
ciple of  ascertaining  the  cause  and  removing  or  correcting  it,  if  at  all 
possible.  In  the  earUer  stages  of  pericemental  inflammation,  it  is 
not  always  an  easy  matter  to  ascertain  the  true  cause  of  the  dis- 
turbance. For  instance,  in  those  cases  following  the  removal  of 
the  pulp  tissue,  it  is  difficult  to  know  whether  the  cause  is  the  root- 
filUng,  the  medicine  used  in  the  treatment,  or  whether  we  failed 
to  estabHsh  and  maintain  asepsis  in  performing  the  operation.  The 
•  author  is  inclined  to  believe  that  it  is  more  frequently  the  latter  than 
most  operators  are  willing  to  admit;  for  certain  it  is  that  the  more 
nearly  we  approach  absolute  asepsis  in  these  operations,  the  less 
pericemental  trouble  we  will  have.  The  teeth  thus  affected  are 
extremely  sore,  and  any  remedy  can  be  used  in  the  treatment  that 
will  give  immediate  relief.  This  is  what  the  patient  most  desires, 
and,  too  often  it  appears,  it  is  that  which  the  dentist  fails  to  give. 
Both  local  and  general  remedies  can  be  employed.  General  remedies 
are  more  valuable  in  the  treatment  of  septic  pericementitis.  If 
they  are  used  at  all  in  treating  nonseptic  pericementitis,  they  should 
be  used  only  in  cases  where  the  patient  is  nervous  and  has  lost  con- 
siderable sleep,  unless  some  drug,  like  nitroglycerin,  is  given  to  relieve 
the  engorged  capillaries.  For  immediate  relief  we  must  depend 
largely  upon  the  local  application  of  drugs  and  remedies.  In  those 
cases  following  the  removal  of  the  pulp  by  either  the  anesthetization 
or  devitahzation  method,  and  where  the  canals  have  not  been  filled, 
the  pain  can  be  relieved  almost  instantly  by  the  following  method: 
Adjust  the  rubber  dam.  If  it  is  necessary  to  use  a  clamp,  it  should 
be  placed  on  the  tooth  posterior  to  the  one  affected.  Sterilize  the 
teeth  included  in  the  dam  and  remove  the  dressing  from  the  canals. 


362  PRACTICAL   DENTAL   THEEAPEUTICS 

Dehydrate  the  tooth-structure  with  modified  alcohol.  Then  wrap 
cotton  loosely  around  a  smooth,  sterile  broach,  dip  in  oil  of  cloves 
or  eugenol,  and  carefully  work  in  each  canal.  Remove  the  broach, 
leaving  the  cotton.  Heat  should  now  be  apphed  to  the  remedy  by 
means  of  a  hot-air  instrument  or  a  chip-blower  until  the  cotton  be- 
comes dry.  Repeat  this  process  several  times,  after  which  the  same 
remedy  should  be  carefully  sealed  within  the  canal.  Under  no 
condition  should  the  cavity  be  left  unsealed.  In  the  above  treatment, 
we  not  only  get  the  benefit  of  the  heat,  which  is  valuable,  but 
the  eugenol,  the  constituent  of  cloves,  is  driven  into  the  tooth-struc- 
ture, producing  a  profound  anodyne  effect  upon  the  sensitive  mem- 
brane. The  author  has  succeeded  in  giving  immediate  rehef  by  this 
method  of  treatment  when  many  others  have  failed.  Grinding  the 
cusps  of  the  tooth  where  it  can  be  done  without  injury  is  advisable;  a 
counterirritant  can  be  appHed  to  the  gum  and  the  patient  dismissed 
for  several  days.  It  is  weU  also  to  prescribe  two  or  three  doses  of 
nitroglycerin  to  faciUtate  the  circulation  of  blood  in  the  membrane. 
It  is  scarcely  necessary  to  instruct  the  patient  to  favor  the  tooth. 

In  the  treatment  of  pericementitis  following  the  filHng  of  the  root, 
having  every  reason  for  beUeving  the  canals  to  be  aseptic,  one  of 
the  last  things  the  author  would  suggest  doing  would  be  to  attempt 
to  remove  the  root- filHng.  Usually  this  only  serves  to  further  aggra- 
vate the  condition.  These  cases  can  best  be  treated  by  counterir- 
ritation  and  general  remedies.  By  counterirritation  is  meant  the 
appHcation  of  an  irritant  to  some  normal  part  of  the  body  for  the 
purpose  of  influencing  favorably  some  other  part,  usually  deep-seated, 
which  is  diseased.  This  irritant  is  generally  applied  to  the  gum  over 
the  affected  tooth.  Capiscum  plasters,  black  mustard  papers  and 
cantharidal  collodion  are  valuable;  or  the  following  liniments,  which 
are  more  generally  used,  give  much  relief : 

I^ — Mentholis,  gr.  xx  (1.3  Gm.) 

Chloroformi,  fSJss  (6.0  mils) 

Tincturae  aconiti,  q.  s.  ad.  f5j  (30.0  mils) — M. 

Sig. — Dry  the  gum  and  apply  freely  over  the  affected  tooth, 
keeping  the  field  dry  for  a  few  seconds 

This  preparation  is  known  as  dental  linifnent. 

I^ — Mentholis, 

lodi  (crys.),  aa     gr.  x  (0.6  Gm.) 

Chloroformi,  fSjss  (6.0  mils) 

Tincturae  aconiti,  q.  s.  ad.  f5j  (30.0  mils) — M. 

Sig. — Make  one  application  to  the  dry  gum  as  above. 

This  liniment  is  called  refrigerant  counterirritant. 


TREATMENT    OF   XOXSEPTIC    PERICEMENTITIS  363 

I^ — ^Liquoris  iodi  compositas,  f5j  (30.0  mils). 

Sig. — Use  as  above. 

This  is  the  official  compound  solution  of  iodin,  known  also  as 
Lugol's  solution. 

Inasmuch  as  tincture  of  aconite  is  an  important  ingredient  in 
many  liniments  used  in  the  local  treatment  of  pericementitis  and 
facial  neuralgia,  it  is  well  to  remember  that  the  United  States 
Pharmacopeia  of  1900  reduced  the  strength  of  this  preparation  from 
35  per  cent,  to  10  per  cent.  This  is  also  the  strength  of  the  prepara- 
tion in  the  U.  S.  P.  IX.  Therefore  the  new  tincture  can  be  employed 
more  freely  in  these  cases  without  danger  of  poisoning.  However, 
care  should  be  taken  to  see  that,  in  applying  remedies  containing 
tincture  of  aconite  to  posterior  teeth,  the  patient  does  not  swal- 
low the  remedy;  especially  should  this  precaution  be  observed  in 
using  dental  liniment. 

As  a  remedy  to  be  apphed  by  the  patient  at  home,  a  split  raisin, 
soaked  in  hot  water,  and  on  which  is  dusted  red  pepper,  can  be  held 
on  the  gum  over  the  affected  tooth.  A  very  efficacious  remedy  is  to 
direct  hot  water  -^-ith  some  force  on  the  part,  beginning  -vN^ith  warm 
water  and  increasing  the  heat  gradually  until  it  is  nearly  boiling. 
This  must  be  kept  up  until  we  get  the  full  benefit  of  the  heat  and 
resolution  is  promoted.  Another  good  remedy  that  the  patient  may 
employ  is  the  hot  foot-bath.  The  value  of  this  remedy,  Hke  the 
appHcation  of  hot  water  to  the  gums,  depends  largely  upon  the  man- 
ner in  which  it  is  applied.  A  deep  foot-bath  tub  should  be  used  and 
the  temperature  of  the  water  gradually  increased  until  it  is  as  hot  as 
can  be  borne.  This  should  be  continued  from  twenty  to  thirty 
minutes. 

There  are  many  other  drugs  and  remedies  which  can  be  employed 
in  the  local  treatment  of  this  condition.  Those  which  have  been 
mentioned  here  the  author  has  found  valuable  in  his  practice.  It  is 
far  better  to  have  a  practical  knowledge  of  a  few  remedies  than  a 
superficial  knowledge  of  many.  The  general  remedies  to  be  admin- 
istered in  the  treatment  of  nonseptic  pericementitis,  if  found  neces- 
sary, will  be  discussed  subsequently  under  the  treatment  of  septic 
pericementitis  and  incipient  abscess,  which  conditions  are  closely 
related. 


DIAGNOSIS  AND  TREATMENT  OF  SEPTIC  PERI- 
CEMENTITIS AND  ACUTE  ALVEOLAR  ABSCESS 

GENERAL  CONSIDERATIONS 

The  treatment  of  septic  pericementitis  and  acute  alveolar  ab- 
scess, as  was  intimated  under  Nonseptic  Pericementitis,  is  so  nearly 
identical  that  the  therapeutics  will  be  discussed  here  conjointly. 
Suppurative  pericementitis  which  occurs  in  the  periapical  area 
means  an  alveolar  abscess,  for  suppuration  implies  the  presence  of 
pus.  In  those  cases  of  gangrenous  pulps  where  the  patient  did  not 
present  for  treatment  until  the  confined  gases  had  escaped  into  the 
periapical  tissue,  carrying  therein  the  bacteria  and  toxins,  we  will 
find  that  a  practical  knowledge  of  pathology  and  therapeutics  will 
serve  us  well.  It  is  in  these  cases  that  good  judgment  must  be  exer- 
cised and  extreme  care  taken.  Frequently  patients  delay  coming 
to  the  dentist  until  the  infection  has  progressed  to  the  point  where 
all  remedies  will  fail  in  preventing  suppuration;  but  in  many  in- 
stances this  result  may  be  attained  by  the  proper  use  of  drugs.  In 
this  connection  it  is  well  to  remember  that  Hopkins,  of  Boston,  a 
few  years  ago  conducted  a  series  of  experiments  in  which  he  proved 
that  not  only  did  bacteria  proliferate  more  rapidly  in  uncared-for 
and  neglected  mouths,  but  that  their  virulency  was  greatly  enhanced. 
Blair  states  that  "certain  pus-producing  organisms,  such  as  the 
Staphylococcus  and  Streptococcus  pyogenes,  will  always  tend  to  pro- 
duce pus.  Often,  however,  owing  to  the  lack  of  virulence  or  lack 
of  sufficient  numbers  in  proportion  to  the  tissue  resistance,  the  inflam- 
matory process  may  be  cut  short  before  it  reaches  the  stage  of  sup- 
puration. Thus  there  may  be  swelling  of  the  gum  and  face  around 
an  infected  tooth,  but  this  may  subside  without  the  formation  of 
pus."  To  this  I  may  add  that  this  is  especially  true  if  the  tooth 
receives  the  proper  treatment. 

Local  Treatment.' — The  local  treatment  here  differs  in  no  par- 
ticular essential  from  that  outlined  for  a  case  of  gangrene  of  the  pulp. 
The  tooth  should  be  located  and  the  pulp-chamber  opened  into  freely, 
under  aseptic  precautions,  holding  the  tooth  in  some  manner  so  that 
the  chisel,  bur  or  excavator  will  not  further  aggravate  the  condition . 
Then  the  cavity  should  be  sprayed  or  washed  with  an  antiseptic 
solution,  dried,  in  this  case  with  alcohol,  and  formocresol  sealed  in 

364 


TREATMENT    OF    SEPTIC    PERICEMENTITIS  365 

the  pulp-chamber  with  cement.  I  know,  to  my  regret,  that  this  is 
not  the  general  method  of  procedure  in  the  handling  of  these  cases; 
but  I  am  certain  that  the  best  results  will  be  obtained  when  we  follow 
the  general  rule  that  all  remedies  should  be  sealed  with  cement. 
This  will  force  us  to  correctly  diagnose  the  condition  and  employ  the 
means  and  remedies  indicated  in  the  rational  treatment  of  the  case. 
Until  we  are  wilHng  to  spend  the  necessary  time  to  accomplish  this 
end,  we  are  not  living  up  to  the  highest  ideals  of  our  calling.  Let 
it  be  remembered  that  as  yet  there  is  no  suppuration  in  these  cases, 
and  any  dentist  who  deliberately  leaves  the  canal  and  cavity  open  to 
external  influences,  or  who  uses  temporary  stopping  because  it  is 
easily  removed,  and  instructs  his  patient  how  to  remove  it  should 
the  tooth  continue  to  ache,  either  does  not  understand  the  condi- 
tion he  is  treating  or  else  he  lacks  confidence  in  his  remedy.  Make 
a  correct  diagnosis,  use  the  proper  remedy  in  the  proper  way  and 
the  tooth  will  not  ache  long — it  matters  not  what  the  pathologic 
condition  may  be. 

General  Treatment.' — After  applying  the  local  remedies,  our 
attention  should  be  given  to  the  treatment  of  the  infection  and 
inflammation  in  the  periapical  area,  which  consists  in  promoting  or 
regulating  the  inflammatory  process.  Again  quoting  from  Blair, 
he  says:  "After  an  infection  has  once  gained  a  foot-hold  in  the 
living  tissue,  we  must  in  our  treatment  regard  not  only  the  infection 
but  the  inflammatory  process  that  it  has  excited.  We  are  not  certain 
that  the  inflammatory  process  itself  ever  needs  treatment,  and  we 
know  that  there  are  very  few,  if  any,  infections  that  could  ever  be 
overcome  without  inflammation.  Inflammation  is  Nature's  way  of 
fighting  infections,  and  we  must  work  with  it,  not  against  it;  for 
otherwiseour  efforts  will  be  in  vain.  *  *  *  One  of  the  first  requisites 
is  the  regulation  of  the  body  functions,  especially  the  excretory 
organs.  In  the  presence  of  an  infection,  the  parenchymatous  cells 
of  various  organs  may  become  sluggish  in  their  action  and  may  require 
stimulation."  In  such  cases  the  skin  may  be  stimulated  by  bathing, 
and  saline  cathartics  are  indicated.  Owing  to  the  faciHty  with  which 
it  can  be  taken  and  its  acceptability  to  the  stomach,  the  official 
solution  of  magnesium  citrate  is  an  excellent  remedy  to  prescribe. 

I^ — ^Liquoris  magnesii  citratis,  f§xij  (360.0  mils). 

Sig. — Take  one-half  at  once  and  the  other  half  in  two  (2) 
hours,  if  necessary. 

Magnesium  sulphate  can  also  be  given  for  the  same  purpose. 
With  this  drug  the  patient  should  be  directed  to  take  a  teaspoonful 


366  PRACTICAL   DENTAL   THERAPEUTICS 

dissolved  in  a  wineglassful  of  warm  water,  having  a  glass  of  cold 
drinking  water  at  hand  to  drink  at  once  after  taking  the  strong 
hyperisotonic  salt  solution.  The  cold  water  .instantly  removes  the 
bitter  and  unpleasant  taste  of  the  salt.  Most  of  .the  large  pharma- 
ceutical houses  to-day  prepare  "effervescent  salt  mixtures,"  of  which 
the  more  important  saHne  carthartics  are  constituents.  These  are 
kept  by  the  pharmacies  and  come  as  a  granulated  powder  which 
when  dissolved  in  water  makes  an  effervescent  solution.  Several 
that  can  be  mentioned  are:  Effervescent  Magnesium  Citrate, 
Effervescent  Magnesium  Sulphate,  Effervescent  Laxative,  Effer- 
vescent Seidlitz  Mixture,  Effervescent  Sodium  Phosphate — any  one 
of  which  can  be  prescribed. 

Potassium  iodid  in  medicinal  doses  can  frequently  be  admin- 
istered, with  beneficial  results.  The  taste  can  be  masked  to  a  large 
degree  by  dissolving  it  in  one  of  the  official  syrups.  The  official 
compound  syrup  of  sarsaparilla  and  aromatic  syrup  of  eriodictyon 
(yerba  santa),  N.F.,  are  both  good.     A  prescription  is  here  given: 

I^ — Potassii  iodidi,  5ss  (6.0  Gm.) 

Syrupi  sarsaparillas  comp.,  fSiij  (90.0  mils) — M. 

Sig. — Take  a  teaspoonful  in  water  after  meals. 

Ordinarily,  the  directions  would  be  as  given,  to  have  the  patient 
take  a  teaspoonful  three  times  a  day  after  meals;  but  in  these  cases 
of  septic  pericementitis  or  incipient  alveolar  abscess  it  is  best  to 
direct  the  patient  to  take  a  teaspoonful  every  two  hours  until  three 
or  four  doses  are  taken,  and  then  follow  the  directions  written  on 
the  label.  A  very  good  remedy  to  have  the  patient  employ  at  home  is 
the  hot  foot-bath;  unless  some  condition  exists  which  is  a  contrain- 
dication, it  is  always  good  practice  to  administer  nitroglycerin  to  de- 
plete the  capillaries  in  the  affected,  and  in  these  cases  infected 
tissues.  As  stated  on  p.  203,  echafolta  is  a  purified,  assayed 
form  of  echinacea — a  drug  which  is  used  extensively  by  eclectic 
medical  practitioners.  The  author  is  able  at  this  time  to  report 
favorably  on  the  use  of  echafolta  in  all  cases  of  infection.  The  dose 
here  is  from  5-30  min.  (0.3-2.0  mils)  given  in  water  every  two  hours, 
until  the  acute  symptoms  subside. 

Heretofore  I  have  prescribed  and  recommended,  purely  on  an 
empirical  basis,  the  salts  of  quinin  in  the  treatment  of  infections  in 
certain  cases.  I  have  since  learned,  however,  that  this  drug  inter- 
feres with  the  ameboid  movement  of  the  white  blood  corpuscles, 
preventing   them   from   migrating  through   the   capillary  walls   in 


Fig.  53. — An  acute  alveolar  abscess  with  extensive  swelling,  involving^  the  entire 
side  of  the  face,  and  completely  closing  the  eye.  If  extraction  of  the  offending  tooth  is 
necessary  to  effect  a  cure,  the  operation  should  be  postponed  until  the  inflammation 
and  swelling  have  been  reduced  by  proper  treatment.  In  this  case  it  was  necessary  to 
make  an  external  incision.  Generally  this  may  be  avoided  by  making  a  deep  intra-oral 
incision,  as  recommended  by  Brophy. 


TREATMENT    OF    SEPTIC   PERICEMENTITIS  367 

inflammation.  The  arrest  of  this  movement  lessens  the  phago- 
cytic power  of  these  scavengers;  therefore,  quinin  is  contraindicated 
in  the  treatment  of  periapical  infections,  unless  we  desire  to  lessen 
tissue  resistance  and  hasten  the  formation  of  pus,  when  it  might 
be  given.  The  salt  which  the  author  prefers  giving,  if  indicated 
in  the  conditions  under  consideration,  is  quinin  bisulphate.  Nearly 
all  pharmacies  have  the  salt  of  quinin  bisulphate  put  up  in  the  form 
of  pills.  While  these  pills  may  be  given,  it  is  much  better  to  write 
a  prescription  for  capsules.  The  gelatin  capsule  is  soon  dissolved 
in  the  stomach;  thus  we  obtain  the  action  of  the  drug  more  rapidly 
than  when  given  in  the  dry,  hard,  pilular  form.  The  following 
prescription  can  be  written  for  the  drug  in  two-grain  doses: 

I^ — Quininse  bisulphatis,  gr.  xxiv  (1.5  Gm.)- 

Ft.  capsulce  No.  xij. 
Sig. — Take  one  capsule  every  hour  until  the  effect  becomes 
noticeable. 

Quinin  acts  differently  upon  different  individuals.  Most  adult 
patients  know  the  effect  of  this  drug  upon  their  systems,  and  therefore 
will  be  able  to  aid  the  dentist  in  determining  the  amount  to  be  taken 
in  a  given  case. 

One  of  the  most  prominent  symptoms  with  which  we  have  to 
contend  here  is  pain.  In  most  cases  the  pain  will  subside  soon  after 
the  local  treatment;  however,  it  is  necessary,  occasionally,  where  the 
patient  is  nervous  and  has  lost  considerable  sleep,  to  administer 
drugs  which  act  upon  the  central  nervous  system,  thereby  controlHng 
the  pain.  There  are  several  drugs  which,  if  properly  given,  will 
produce  the  desired  effect.  The  official  compound  powder  of  ace- 
tanilid  is  here  recommended  and  can  be  prescribed  as  follows : 

I^ — Pulveris  acetanilidi  comp.,  gr.  xij  (0.8  Gm.) 

Ft.  chartulae  No.  ij. 
Sig. — Take  one  powder  at  once  and  the  other  in  two  (2)  hours, 
if  not  relieved. 

Another  very  useful  prescription  for  acetanilid  is  one  suggested  by 
Harlan.     It  follows: 

I^ — Acetanilidi,  gr.  viij  (0.5  Gm.) 

Syrupi  simplex,  fgss  (15.0  mils). 

Spiritus  frumenti,  q.  s.  ad.  f§iij  (90.0  mils) — M. 

Sig. — Take  one-half  at  once  and  the  remainder  in  two  (2) 
hours,  if  not  relieved. 


368  PRACTICAL    DENTAL    THERAPZUTICS 

Keefe.  of  Chicago.,  suggests  using  dilute  alcohol  by  which  in- 
stantaneous and  often  permanent  relief  can  be  obtained  in  those  cases 
where  the  tooth  involved  is  one  of  the  six  upper  anterior  teeth.  A 
prescription  for  the  remedy  is  here  given: 

E — Alcoholis, 

Aquae,  a  a     foj  .30.0  mils'.' — 'M. 

Sig. — Use  as  directed. 

This  remedy  is  best  administered  in  the  form  of  a  spray,  using  a 
watch-case  atomizer  for  liquids,  forcing  the  spray  well  back  into  the 
nostril  on  whichever  side  the  afiected  tooth  is  located.  The  apphca- 
tion  can  be  repeated  as  often  as  is  necessary,  without  any  ill  effects. 
In  case  an  atomizer  of  any  kind  is  not  at  hand,  about  fifteen  minims 
(i.o  mil)  of  the  remedy  can  be  placed  far  back  in  the  nostril  with  a 
suitable  syringe. 

The  author  does  not  wish  to  be  understood  as  suggesting  these 
various  internal  remedies  in  all  cases  of  acute  abscess.  Xo  therapeu- 
tist can  tell  exactly  what  internal  drugs  he  would  suggest  v.-ithout 
seeing  th€  case  and  knowing  the  history;  for  there  are  many  circum- 
stances and  conditions  which  modify  the  efiect  of  drugs.  Every 
remedy  here  mentioned,  however,  v,-ill  be  foimd  useful  in  certain 
cases. 

The  Question  of  Extraction. — The  question  of  extraction  in 
acute  alveolar  abscess  is  a  disputed  one.  Many  writers  recommend 
extraction   as  a   speedy   means   of    affording   rehef    (see   Fig.    S5^- 


Fig.  54. — This  shovrs  a  sequestrum  which,  was  exfoliated  from  the  lovrer  javr.  This 
result  followed  extensive  infection,  endangering  the  life  of  the  patient,  and  uldmate 
necrosis  from  the  extraction  of  a  lower  second  bicuspid  root  during  the  acute  stage  of 
an  alveolar  abscess.  A  mLxed  infection  doubdess  resulted  from  the  laceration  of  tissues. 
It  wdl  be  noticed  that  the  sequestrum  contains  the  mental  foramen,  which  means,  of 
course,  that  the  inferior  dental  nerve,  arter\-,  and  vein  were  severed.  The  Up  on  the 
afiected  side  was  partially  paralyzed  for  a  period  of  two  or  three  years;  and,  in  opening 
into  the  first  bicuspid  for  the  purpose  of  pulp  removal  for  bridge-work,  six  months  later, 
the  pulp  was  dead  and  just  beginning  to  "undergo  the  process  of  decomposition.  I 
rather  suspected  a  specific  his  ton.-,  but  was  unable  to  confirm  the  suspicion. 

Unfortunately,  however,  this  is  not  always  the  solution  of  the 
problem;  for  if  there  be  much  osteomyehtis  and  the  roots  of  the 
offending  tooth  be  firmly  embedded,  it  is  a  rather  dangerous  pro- 
cedure to  extract  during  the  developmental  stage,  on  account  of  the 
liabilitv  of  a  mLxed  infection,  resulting  oftentimes  in  necrosis  and 


TREATilEXT    OF    SEPTIC    PERICEMENTITIS  369 

frequently  even  th.reatening  the  life  of  the  patient  (see  Fig.  54). 
If  the  root  be  a  worthless  one  and  easily  extracted,  its  removal  would 
doubtless  afford  free  drainage  for  the  abscess.  There  is  no  set 
rule  governing  extraction  in  these  cases.  The  operator  must  be 
guided  largely  by  the  conditions  as  found.  When  extraction  is 
resorted  to,  antiseptic  mouth-washes  should  be  prescribed  and  the 
case  watched  closely  for  a  few  days  until  we  are  certain  that  no  com- 
plication will  follow. 


CHRONIC  ALVEOLAR  ABSCESS 

GENERAL  CONSIDERATIONS 

There  are  two  varieties  of  chronic  alveolar  abscesses — those 
without  an  external  opening  except,  perhaps,  through  a  cavity  in  the 
offending  tooth,  and  those  which  are  discharging  through  a  sinus.  In 
these  cases  the  decomposition  of  the  pulp  tissue  is  complete;  the  inter- 
mediate products  (ptomains  and  amido-acids)  have  largely  been 
broken  up,  and  pus  has  been  formed  from  the  tissue  and  fluids  sur- 
rounding the  ends  of  the  roots.  Wherever  it  is  possible,  a  radiograph 
of  the  affected  tooth  and  periapical  area  should  be  obtained;  for 
upon  the  radiographic  findings  to  a  large  degree  will  our  decision 
depend  as  to  whether  the  case  should  be  treated  medicinally,  surgically, 
or  both.  In  the  past  many  teeth  with  chronic  alveolar  abscess  as- 
sociated therewith  have  been  retained  in  the  mouth,  in  utter  disregard 
of  the  possible  deleterious  effects  they  might  have  on  the  general 
health  of  the  patient.  This  will  not  be  the  practice  of  dentists  in 
the  future;  though  it  may  safely  be  said  that,  at  the  present  time, 
many  teeth  are  being  sacrificed  which,  under  proper  treatment, 
might  be  saved  without  menacing  or  jeopardizing  the  patient's  health. 

I.  ABSCESS  WITHOUT  SINUS 

In  treating  that  variety  of  alveolar  abscess  which  is  without  an 
external  opening,  our  method  of  procedure  is  somewhat  different 
from  that  of  an  acute  abscess.  The  tooth  should  be  located;  the 
rubber  dam  adjusted,  and  the  teeth  sterilized  as  before;  then  the  pulp 
chamber  is  opened  with  a  suitable  round  bur. 

Disposing  of  the  Pus. — Usually  the  pus  flows  freely,  in  which 
case  it  is  permitted  to  do  so,  pressure  being  made  on  the  tissue  im- 
mediately over  the  end  of  the  root.  It  should  be  our  effort  to  me- 
chanically evacuate  as  much  pus  at  each  sitting  as  is  possible;  for  it 
is  far  better  to  remove  pus  in  this  manner,  when  it  can  be  done,  than 
to  depend  upon  some  chemic  agent  to  destroy  it,  or  upon  Nature  to 
dispose  of  it. 

THERAPEUTICS 

The  formocresol  remedy  will  be  useful  here.  The  canals  should 
be  dried  with  alcohol  as  thoroughly  as  possible  and  the  remedy  on 

370 


CHRONIC   ALVEOLAR   ABSCESS  371 

cotton  hermetically  sealed  in  each  canal.  It  is,  however,  at  this 
sitting,  impossible  to  get  the  canals  dry,  and  it  is  unnecessary  to  have 
them  so,  for  the  remedy  will  penetrate  where  moisture  is  present. 
This  is  an  advantage  over  most  remedies  suggested  for  this  purpose. 
In  those  cases  where  there  is  pain  and  swelling,  together  with  a 
copious  flow  of  pus  which  seemingly  cannot  be  checked  at  this  time, 
it  may  be  necessary  to  evacuate  the  pus  as  completely  as  possible, 
loosely  place  in  the  canal  a  few  shreds  of  cotton  saturated  with  an 
antiseptic  remedy  (phenol  compound),  and  then  place  in  the  cavity 
a  pledget  of  cotton  dipped  in  liquid  petroleum.  In  no  case  should 
the  cavity  be  left  entirely  open;  and  the  author  desires  to  emphasize 
that  it  is  seldom  necessary  to  resort  to  this  temporary  expedient,  if 
the  proper  time  is  spent  in  opening  into  the  tooth  and  evacuating  the 
pus.  The  dressing,  in  any  event,  should  be  changed  every  day  until 
it  can  be  removed  without  the  pus  flowing  from  the  canals.  When 
pus  is  forming  rapidly  at  the  ends  of  the  roots,  the  dressing  soon  be- 
comes dissipated,  the  remedy  loses  its  effect,  and  it  is  a  loss  of  time 
to  leave  it  in  the  canals  more  than  twenty-four  hours.  Unless  there 
be  some  complication,  the  pus  formation  should  be  checked  in  one 
or  two  treatments,  at  which  time  phenolsulphonic  acid  can  be  used 
in  the  same  manner  as  in  the  treatment  of  gangrenous  pulps,  and 
eucalyptol  compound  sealed  in  the  canal  with  the  double  sealing 
material  as  elsewhere  explained.  It  is  now  possible  to  change  the 
dressings  too  often,  however.  The  formation  of  pus  has  been 
checked,  and  the  tooth  should  not  be  disturbed  for  at  least  one  week 
or  ten  days,  in  order  to  give  Nature  a  chance  to  effect  a  cure.  If,  at 
the  end  of  this  time,  there  is  no  evidence  of  pus  and  the  case  gives  a 
favorable  history,  the  canals  can  be  filled.  Should  there,  however, 
be  a  slight  odor,  although  the  tooth  has  not  caused  any  trouble,  we 
are  not  justified  in  filling  the  root.  In  these  cases  we  may  suspect  a 
root-end  involvement,  or  some  other  complication,  when  the  radio- 
graph is  invaluable.  Formocresol  may  be  used  again  as  in  the  initial 
treatment;  but  it  should  be  remembered  that  the  value  of  formal- 
dehyd  in  any  remedy  to  be  used  in  the  treatment  of  these  conditions 
depends  upon  the  power  this  agent  has  of  uniting  chemically  with 
hydrogen  sulphid,  ammonia  and  poisonous  ptomains.  When 
these  substances  are  not  present,  formaldehyd  should  be  used  with 
care  and  judgment.  This  precaution  is  mentioned  here  because 
formaldehyd  is  an  irritating  gas,  and  the  amount  of  any  remedy  con- 
taining it  should  be  in  accordance  with  the  conditions  as  found. 

Weeping  of  Serum. — Quite  frequently  in  these  alveolar  abscess 
cases,  after  the  formation  of  pus  has  been  checked,  we  have  a  weep- 


372  PRACTICAL   DENTAL   THERAPEUTICS 

ing  of  serum  from  the  canals.  An  excellent  remedy  to  use  in  this 
case  is  eucal3T)tol  to  which  thymol  has  been  added  in  the  following 
proportion: 

I^ — Thymolis,  gr.  x  (0.6  Gm.) 

Eucalyptolis,  f5j  (4-o  mils) — M. 

Sig. — Dry  the  canal  as  thoroughly  as  possible  and  hermetically 
seal  in  the  remedy. 

If  this  remedy  fails  to  check  the  secretion  and  the  fluid  is  serum, 
not  pus,  no  hesitancy  need  be  felt  as  to  filling  the  root,  although  the 
canals  cannot  be  dried.  The  condition  should  not  be  confused  with 
a  cyst,  which  quite  frequently  occurs  in  the  apical  area  of  teeth. 
Brophy  defines  a  cyst  as  a  sac  containing  fluid,  or  a  semi-fluid  sub- 
stance, which  may  be  gelatinous  or  inspissated.  A  cyst  may  con- 
tain mucus,  saliva,  bile,  urine,  etc.,  depending  upon  the  organ  with 
which  it  is  associated.  It  should  not  be  diflicult  to  differentiate 
cystic  fluid  from  normal  serum  which  also  frequently  fiJls  a  cavity 
formed  by  an  abscess.  In  fact  the  serum  contains  the  elements  with 
which  Nature  rebuilds  the  lost  tissue.  If  a  cyst  is  suspected  the 
diagnosis  should  be  confirmed.  The  treatment  of  a  cyst  is  surgical, 
for  which  the  reader  is  referred  to  works  on  Oral  Surgery. 

Complications. — Occasionally  we  find  a  chronic  alveolar  abscess 
of  this  variety  where  it  is  almost  impossible  to  check  the  formation 
of  pus  by  applying  drugs  to  the  canals  of  the  teeth.  In  those  cases 
where  the  pus  continues  to  flow  freely  when  the  dressing  is  removed 
at  the  third  or  fourth  sitting,  some  complication  can  be  expected. 
It  is  necessary  then  to  force  some  stimulating  agent  through  the 
apices  of  the  roots,  after  the  pus  has  been  mechanically  evacuated. 
The  stimulating  agent  which  the  author  uses  almost  invariably  is 
phenolsulphonic  acid.  In  resorting  to  this  means  of  bringing  about 
a  more  acute  condition,  I  desire  to  emphasize  the  necessity  of  first 
evacuating  the  pus  as  completely  as  possible  before  using  the  remedy, 
after  which  the  agent  should  be  placed  in  the  canal  on  cotton  and 
gently  forced  through  the  apices,  then  neutralizing  that  which  remains 
with  a  solution  of  sodium  bicarbonate,  desiccating  the  canal  with 
alcohol  and  hermetically  sealing  therein  an  antiseptic  like  phenol  com- 
pound or  eucalyptol  compound.  It  will  be  found  that  one  or  two 
treatments  will  usually  check  the  formation  of  pus,  after  which  the 
case  can  be  treated  as  an  ordinary  abscess  of  this  kind.  In  case  this 
method  fails  to  effect  a  cure,  however,  it  will  be  necessary  to  estab- 
lish surgically  an  opening  through  the  overlying  process  and  soft 
tissue  and  treat  as  for  an  ordinary  discharging  abscess — which 
treatment  will  be  considered  later. 


Fig.  55. — A  chronic  alveolar  abscess  from  an  upi  _:  !_-:  niolar,  where  the  pus  in 
making  its  exit  worked  its  way  upward  and  outward,  over  the  outer  wall  of  the  antrum 
and  opened  externally  on  the  face.  The  tooth  was  badly  decayed  and  was  extracted 
May  12,  191 2.  The  picture  was  taken  two  days  later.  The  case  >"ielded  nicely  to 
treatment,  which  consisted  in  washing  the  part  with  an  antiseptic  solution,  lea\"ing 
only  a  sHght  indentation  on  the  cheek.  This  case  is  unusual.  Generally  these  abscesses 
open  within  the  mouth  or  occasionally  into  the  antrum,  rarely  externally.  Abscesses 
from  lower  teeth  frequently  discharge  externally  (see  Fig.  83). 


CHRONIC   ALVEOLAR   ABSCESS  373 

Hypertrophied  Alveolar  Process. — This  condition  is  quite  fre- 
quently associated  with  abscesses  without  a  sinus,  or  a  low  chronic 
inflammation  of  the  alveolar  process  due  to  septic  foci  at  the  root- 
ends  of  pulpless  teeth.  It  is  the  safest  practice  to  extract  teeth  which 
have  caused  hypertrophy  of  the  alveolar  process.  Even  the  aseptic 
treatment  and  filling  of  the  canals  of  the  affected  teeth  will  not 
reduce,  in  many  cases,  the  hypertrophied  process,  and  to  permit  it  to 
remain  might  lead  to  an  osteoma  or  an  osteosarcoma  (Marshall). 

2.  ABSCESS  WITH  SINUS 

In  those  cases  where  the  pus  is  discharging  into  the  mouth  through 
a  sinus,  our  first  duty  is  to  locate  the  offending  tooth.  This  is  gener- 
ally a  simple  matter  fpr  the  reason  that  the  sinus  usually  opens  imme- 
diately over  the  tooth  from  which  it  comes.  The  pus  in  making  its 
exit,  however,  follows  the  line  of  least  resistance,  and  in  some  cases 
the  condition  of  the  process  is  such  that  the  pus  burrows  forward 
or  backward,  and  opens  through  the  gum  at  a  point  several  teeth 
removed  from  the  one  which  is  causing  the  trouble.  (Fig.  55.) 
These  are  the  cases  that  are  difficult  to  diagnose,  especially  when 
the  abscess  has  been  discharging  for  some  time,  when  there  is  not 
much  tenderness  in  any  special  tooth,  and  when  there  are  several 
pulpless  teeth  on  this  side  of  the  mouth.  Sometimes  two  or  more 
teeth  containing  gangrenous  pulps  have  a  common  sinus  (see  Fig. 
65  and  Figs.  83  and  84).  In  this  case  it  would  be  impossible  to  heal 
the  tract  by  treating  only  one  of  the  teeth.  The  use  of  a  silver  probe 
will  be  valuable  in  all  such  cases.  By  gently  working  the  probe 
forward  or  backward  the  sinus  can  be  explored  and  the  offending 
tooth  or  teeth  located  without  drilling  into  innocent  teeth — a  discour- 
aging procedure  to  both  patient  and  dentist.  In  all  such  cases  the 
radiograph  is  an  invaluable  aid  in  diagnosis. 

THERAPEUTICS 

The  tooth  being  located,  all  that  is  necessary  to  effect  a  cure — 
there  being  no  complication — is  to  clean  the  canal  with  acids  or 
alkalies,  preferably  the  former,  and  then  force  some  bland  solution 
through  the  root-canal  and  sinus,  thus  being  certain  it  is  well  estab- 
lished; cauterize  the  tract  with  phenolsulphonic  acid,  or  other  stimu- 
lating cauterant,  hermetically  seal  in  the  canal  or  canals  an  anti- 
septic, like  phenol  compound  or  eucalyptol  compound,  and,  at  the 
subsequent  sitting,  the  case  giving  a  favorable  history,  fill  the  root 


374  PRACTICAL   DENTAL   THEEAPEUTICS 

Establishing  Sinus  and  Disposing  of  Pus. — If  the  abscess  is 
not  discharging,  and  in  those  cases  where  it  is  discharging,  it  is  well 
before  adjusting  the  rubber  dam  to  enlarge  the  mouth  of  the  sinus 
with  a  lancet  or  bistoury.     By  dipping  the  lancet  in  phenol,  this 
may  be  accomplished  with  very  Uttle  pain  to  the  patient.     After 
this  is  done,  the  rubber  dam  should  be  adjusted  and  the  canals  freely 
exposed.     Now  that  the  infection  is  past  the  end  of  the  root,  we 
need  not  hesitate  to  clean  the  canal  at  this  sitting  by  chemico- 
mechanical  means.     The  canals  being  clean,  we  are  ready  to  establish 
the  sinus.     To  do  this  we  need  a  bland  solution  and  a  good  hypo- 
dermic syringe  with  a  long  straight  needle  for  anterior  and  a  long 
curved  needle  for  posterior  teeth.     There  is  an  advantage  in  having 
a  long  needle,  for  the  nearer  the  point  is  to  the  apex  of  the  root,  the 
less  packing  and  force  are  required  to  send  the  solution  through  the 
sinus.     Any  bland  solution  can  be  used  for  this  purpose.     The  author 
suggests  physiologic  saline  solution  or  peppermint  water  to  which 
2  min.   (0.12   mil)   of  phenol  have  been  added  to  the  fluidounce 
(30.0  mils).     A  piece  of  unvulcanized  rubber  of  the  proper  size 
should  be  selected,  softened  in  the  flame,  and  a  hole  made  in  the 
center  through  which  the  needle  is  placed  and  inserted  into  the  canal. 
The  rubber  should  now  be  tightly  packed  around  the  needle  and  held 
on  either  side  with  flat-nose  pHers,  when  pressure  can  be  made  on 
the  piston  of  the  syringe  and  the  solution  forced  through  the  sinus. 
This  should  be  repeated  several  times,  care  being  taken  not  to  break 
the  needle  in  the  canal.     If  convenient,  one  corner  of  the  dam  can  be 
raised,  exposing  the  mouth  of  the  sinus  to  view.     There  are  two 
objects  in  forcing  a  bland  solution  through  the  sinus:  one  is  to  be 
certain  that  it  is  open,  and  the  other  is  to  mechanically  wash  out  the 
pus.     Whenever  pus  can  be  mechanically  removed,  it  is  always  better 
to  dispose  of  it  by  this  means  rather  than  to  do  so  by  the  use  of  some 
chemic  agent.     It  has  been  a  common  practice,  after  establishing 
the  sinus,   to    use    a  solution  of  hydrogen  dioxid.     This  is  often 
a  dangerous  procedure  and  always  unnecessary  if  the  first  solution  has 
been  used  in  sufficient  quantity. 

Cauterizing  Sinus. — For  cauterizing  the  sinus  in  simple  cases 
95  per  cent,  phenol  has  been  largely  employed.  An  excellent  prepa- 
ration to  use  for  this  purpose  is  the  phenolsulphonic  acid.  With 
the  sinus  well  established,  it  is  never  necessary  to  place  either  of 
these  solutions  in  a  hypodermic  syringe.  The  author  knows  of 
several  instances  where  this  has  been  tried  with  disastrous  results. 
The  remedy  can  be  appHed  to  the  canals  on  cotton,  when,  with  unvul- 
canized rubber  and  a  suitable  instrument,  it  can  be  forced  through 


CHRONIC   ALVEOLAR   ABSCESS 


375 


the  sinus.  Alcohol  is  a  positive  antidote  for  phenol;  if  this  agent  is 
used,  the  alcohol  bottle  should,  therefore,  be  in  a  convenient  place  so 
that  the  remedy  used  in  the  canal  can  be  neutralized  at  once  when  it 
appears  at  the  mouth  of  the  sinus,  Phenolsulphonic  acid  may  be 
neutralized  in  this  case  with  alcohol  followed  with  a  solution  of  sodium 
bicarbonate.  If  this  has  been  well  done,  it  matters  little  what  drug 
or  remedy  is  sealed  in  the  canal.  The  phenol  compound  or  eucalyp- 
tol  compound  remedy  will  give  excellent  results  if  hermetically  sealed 
in  the  canals  for  about  one  week,  always  using  the  double  sealing 
process. 

In  cases  of  long  standing  when  we  can  reasonably  suspect  a  rough- 
ening of  the  end  of  the  root  or  process  through  which  the  pus  has  been 


Fig.  56. — This  radiograph  illustrates  an  interesting  case,  which  was  not  treated  by 
the  author  and  the  history  is,  therefore,  negative.  The  radiograph  shows  that  the 
canal  is  not  properly  filled,  while  the  root  carries  a  well-adjusted  porcelain  crown.  It 
is  futile  to  attempt  to  cure  an  abscess  under  such  conditions  by  simply  injecting  such 
an  agent  as  bismuth  paste  through  the  sinus  into  the  affected  area.  The  crown  must  be 
destroyed,  the  canal  reopened,  when  one  or  two  treatments  of  phenolsulphonic  acid 
should  effect  a  cure.  Had  the  radiograph  shown  that  the  canal  was  properly  filled, 
external  curettement  would  have  been  the  proper  treatment.  In  fact,  had  the  canal 
been  properly  filled,  the  abscess,  in  all  probability,  would  not  have  developed. 


discharging,  it  is  best  to  depend  upon  phenolsulphonic  acid  as  the 
cauterizing  agent  (see  Fig.  56).  This  agent,  as  heretofore  made,  con- 
tained an  excess  (15  per  cent.)  of  uncombined  sulphuric  acid,  which 
rapidly  disintegrated  cotton;  therefore,  it  was  necessary  to  place  it 
in  the  canal  on  threads  of  asbestos,  wool  fiber,  or  silk,  and  force  it 
through  the  sinus  in  the  usual  manner,  cauterizing  the  tract,  and  also 
stimulating  the  sluggish  cells  in  the  area  to  healthy  activity.  It  is 
now  possible  to  procure  phenolsulphonic  acid  with  less  than  i  per 
cent,  of  free  sulphuric  acid  (see  p.  95).  This  product  can  be  used 
'with  cotton. 

It  is  sometimes  difficult  to  establish  the  sinus,  especially  on 
molar  teeth.     In  all  such  cases,  if  there  is  no  compHcation,  the 


376 


PRACTICAL   DENTAL   THERAPEUTICS 


treatment  can  be  that  outlined  under  Treatment  of  Abscess  Without 
Sinus. 

The  author  does  not  believe  in  delaying  the  root-filling  long  after 
the  sinus  has  been  cauterized  in  uncompHcated  cases;  for  by  filling 
the  root  as  soon  as  we  are  certain  that  the  sinus  is  heahng,  we  avoid  a 
weeping  condition,  which  usually  exists  and  which  is  annoying  when 
this  part  of  the  treatment  is  delayed  for  one  month  or  six  weeks  as 
advocated  by  some  writers.  In  these  case's  where  the  first  treatment 
has  been  thorough,  and  the  case  gives  a  favorable  history,  the  root 
should  be  filled  at  the  second  or,  at  latest,  the  third  sitting.  If  the 
case  does  not  yield  to  the  above  treatment,  some  complication  may 
be  suspected. 

COMPLICATIONS 

There  are  several  complications  of  chronic  alveolar  abscess  of 
both  varieties,  with  and  without  a  sinus,  where  it  is  necessary  to 


Fig.  57- 

Fig.  57. — This  radiograph  shows  an  abscess  with  extensive  resorption  of  alveolar 
process  between  the  central  and  lateral  roots,  both  of  which  had  been  previously  filled 
and  carried  jacket  crowns.  The  radiograph  shows  the  lateral  root  perfectly  filled  and 
the  abscess  caused  by  the  imperfectly  filled  central.  These  cases  are  often  diflacult  to 
diagnose. 

Fig.  s8. — This  radiograph  shows  a  simUar  case  to  that  illustrated  in  Fig.  57.  It 
was  difficult  to  determine  whether  the  abscess  came  from  the  central  or  lateral  root. 
The  radiograph  shows  the  lateral  root  over-filled,  but  the  abscess  coming  from  the 
central. 


modify  or  change  the  general  method  of  treatment  to  meet  the  condi- 
tions as  they  exist.  For  instance,  in  the  case  of  an  abscess  without  a 
sinus  where  we  can  reasonably  suspect,  and  where  the  indications 
point  to,  a  roughening  of  the  end  of  the  root,  we  ought  not  to  expect 
to  cure  the  case  by  simply  seaHng  remedies  within  the  canals  of  the 
tooth.  If  we  do,  we  are  expecting  too  much  of  drugs.  Again,  in  a 
case  of  abscess  with  a  sinus  where  the  pus  has  been  discharging  for 


Labial  glands. 
Muscle 


Muscles. 


Sinus. 


Fig.  59. — Chronic  abscess  discharging  under  the  chin. 


CHRONIC   ALVEOLAR   ABSCESS 


377 


several  months,  with  the  not  unusual  result  that  the  end  of  the  root  or 
process  through  which  the  pus  has  discharged  has  become  roughened, 
we  should  not  expect  to  effect  a  cure  by  forcing  phenol  or  the  phenol 
compound  through  the  sinus,  because  such  agents  as  these  have  no 
action  whatever  on  the  bony  structures.  The  author  desires  to 
emphasize  again  the  value  of  the  radiograph  in  determining  the 
extent  of  involvement  and  the  nature  of  the  complication.  It  is 
not  always  a  positive  means  of  diagnosis,  but  it  is  a  material  aid 
(see  Figs.  57  and  58,  also  Fig.  59). 

1.  Denuded  End  of  Root. — One  complication  we  may  expect  to 
find  in  abscesses  of  long  standing,  especially  in  the  variety  without  a 
sinus,  is  where  a  large  area  of  tissue  in  the  periapical  area  has  been  re- 
sorbed  or  broken  down,  denuding  the  end  of  the  root  and  the  denuded 


Fig.  60. — This  radiograph  shows  a  typical  abscess  without  a  sinus  which  developed 
from  an  imperfectly  filled  root  of  a  lateral  incisor. 


portion  projecting  into  the  absorbed  area  (see  Fig.  60) .  It  is  possible, 
in  these  cases,  to  make  pressure  over  the  end  of  the  root  and  mechani- 
cally evacuate  all  of  the  pus  above  the  apices ;  but  we  cannot  expect 
by  this  means  to  evacuate  the  pus  below  and  surrounding  the  end  of 
the  root  projecting  into  the  space.  In  this  case  we  must  do  one  of 
two  things:  Force  some  stimulating  agent  through  the  end  of  the  root 
into  the  infected  area,  to  create  a  more  acute  condition ;  or  surgically 
estabhsh  a  sinus  through  the  overlying  process  and  soft  tissue,  and 
treat  as  an  ordinary  discharging  abscess.  While  the  author  does  not 
hesitate  to  adopt  the  latter  method  if  necessary  to  effect  a  cure,  it  will 
be  found  that  the  use  of  a  stimulating  agent  will  generally  suflace  in 
these  cases.  The  agents  recommended  are  phenolsulphonic  acid  or  a 
15  per  cent,  solution  of  trichloracetic  acid.  In  using  either  of  these 
solutions,  the  pus  should  first  be  evacuated  as  much  as  is  possible; 
then  the  solution  selected  can  be  placed  in  the  canal  and  gently 


378  PE_\CTICAL   DENTAL   THERAPEUTICS 

forced  through  the  apices,  and  an  antiseptic  sealed  in  the  canal. 
One  or  two  treatments  \vill  usually  be  sufficient  to  check  the  pus 
formation,  when  the  case  can  be  treated  in  the  ordinary  manner.  If, 
however,  this  does  not  effect  a  cure,  it  is  a  waste  of  time  to  prolong 
such  treatment,  and  recourse  should  be  made  to  surgical  methods, 
which  will  be  discussed  later. 

2.  Resorbed  or  Roughened  End  of  Root. — Another  compHca- 
tion  of  both  varieties  of  chronic  alveolar  abscess  is  where  the  pus 
has  been  in  contact  with  the  end  of  the  root  sufficiently  long  to 
cause  resorption,  leaving  a  roughened  end  which  irritates  the  tissue 


Fig.  61. — This  shows  an  upper  second  bicu-pid  exfoliated  by  Xature  with  the  entire 
surrounding  alveolar  process  attached  This  re-ult  followed  a  slight  traumatic  injury 
to  the  part,  shortly  after  the  pulp  had  been  removed  by  pressure  anesthesia.  The 
first  bicuspid  ultimateh-  became  so  loose  that  its  removal  was  necessary.  The  author 
was  able  to  elicit  a  preWous  historj-  of  s^-philis,  the  disease  having  been  cured  a 
number  of  years  before. 

and  prevents  heahng.  Sometimes,  also,  the  process  through  which 
the  pus  has  burrowed  is  left  with  sharp  edges.  In  all  such  compli- 
cations, surgical  treatment  is  especially  indicated.  These  cases 
generally  yield  nicely  to  the  removal  of  the  denuded  and  roughened 
root-end,  and  the  thorough  curettement  of  the  aff"ected  area. 

3.  Encystment  of  Root. — A  difficult  compHcation  to  treat  is 
an  abscess  which  forms  on  a  root,  the  end  of  which  has  become 
encysted  from  deposits,  excementosis  or  other  causes.  In  order  to 
effect  a  cure  in  these  cases,  it  is  necessary  to  establish  a  sinus  and 
remove  the  deposits,  excise  the  root-end,  or  extract  the  tooth.  The 
method  of  excising  the  root-end  wiU  be  discussed  later. 

4.  Involving  Bone. — Every  acute  and  chronic  alveolar  abscess 
invites  bone  complication.  During  the  progress  of  the  abscess  the 
bone-marrow  (spongiosum)  becomes  infected  by  the  pathogenic 
bacteria  and  is  broken  down  into  pus.  If  extraction  is  resorted  to 
and  laceration  of  the  soft  tissue  and  alveolar  margins  results^  a 
mixed  infection  is  liable  to  follow,  as  has  been  previously  stated. 
The  germs  are  highly  virulent,  and  among  them  are  frequently  found 
the  diplococcus  pneumoniae  and  the  tubercular  bacillus,  as  well  as 
the  streptococcus  viridans. 


CHRONIC   ALVEOLAR   ABSCESS 


379 


In  these  cases  it  is  necessary  to  see  the  patient  frequently,  wash- 
ing the  part  with  warm  antiseptic  solutions  and  covering  the  entire 
exposed  process  with  the  euroform  paste  or  other  stimulating 
remedies.  The  orthoform  will  control  the  pain  and  the  iodin  Hber- 
ated  from  the  europhen  will  stimulate  and  disinfect  the  part.  If 
gauze  is  used  in  applying  the  paste,  it  should  be  changed  frequently; 
for,  if  left  long,  it  invites  further  infection,  even  when  saturated 
at  first  with  the  oleaginous  paste.  After  the  pain  subsides  bismuth 
paste  may  be  freely  injected  every  few  days.  In  employing  the 
latter  remedy,  however,  care  should  be  taken  to  prevent  the  wound 
from  healing  over  the  paste.  The  author  has  observed  several 
cases  where  the  part  had  to  be  reopened  after  several  months  and 
the  bismuth  paste  removed,  since  it  is  not  absorbed,  as  was  supposed 
at  first. 


Fig.  62. — This  radiograph  shows  bismuth  paste  which  was  injected  into  an  abscess 
pocket.  Extensive  caries  of  bone  resulted  from  a  dead  pulp  in  the  cuspid  tooth.  An 
opening  was  made  both  labially  and  lingually,  the  part  curetted  and  packed  with 
euroform  gauze.  The  second  day  after  operation  the  bismuth  paste  was  injected,  and 
the  radiograph  taken. 


5.  Extensive  Caries  or  Necrosis. — Bone  infection  from  alveolar 
abscesses  often  results  in  either  caries  or  necrosis  of  bone.  Pus  is 
formed  from  the  breaking  down  of  the  tissues  and  fluids,  and,  in  case 
of  caries,  escapes  through  several  sinuses  (see  Fig.  62).  The  porous 
dead  bone  may  be  detected  by  a  pointed  steel  probe.  In  necrosis 
the  parts  involved  die  en  masse,  and  the  sequestra  are  finally  loosened 
and  gradually  work  out  as  one  large  or  several  small  pieces.  In  cases 
with  a  syphilitic  history,  even  if  the  case  has  long  been  considered 
cured,  there  is  a  great  tendency  toward  necrosis  (see  Fig.  61).  The 
treatment  here  is  largely  surgical.  The  dead  bone  must  be  removed, 
after  which  the  parts  should  be  kept  clean  and  stimulated  until 
healed.  It  is  generally  best  in  cases  of  necrosis  to  wait  for  Nature 
to  separate  the  dead  from  the  hving  bone.     A  50  per  cent,  solution 


38o 


PRACTICAL   DENTAL    THERAPEUTICS 


of  phenolsulphonic  acid  hastens  the  formation  of  the  sequestrum; 
after  the  dead  bone  is  removed  bismuth  paste  should  be  injected 
until  the  part  heals. 

6.  Involving  Vault. — Still  another  complication  often  difficult  to 
cure  ig  where  the  pus  has  worked  its  way  through  the  lingual  plate 
of  bone  and  involves  the  vault  of  the  mouth  (see  Figs.  63  and  64). 
The  dense  fibrous  tissue  covering  the  vault  is  very  tough,  and  the 
pus  often  separates  the  periosteum  from  a  considerable  area  of  bone 
before  ultimately  discharging  into  the  mouth.     Generally  a  lancet 


Fig.  03.  ,  Fig.  64. 

Fig.  63. — This  radiograph  shows  a  large  abscess  cavity  under  the  floor  of  the  nasal 
and  antral  cavities,  the  result  of  the  death  and  decomposition  of  the  pulp  in  the  lateral 
incisor.  The  dark  spot  shows  the  outUne  of  the  cavitj^  which  had  been  injected  with 
bismuth  paste  from  a  hngual  opening.  To  cure  the  case  it  was  necessary  to  open  from 
the  labial,  excise  the  lateral  root  and  thoroughly  curette  the  affected  bone.  .Ai ter  the 
operation  the  case  was  first  packed  for  24  hours  with  euroform  gauze  to  control  the 
pain,  followed  with  the  injection  of  bismuth  paste  until  granulation  filled  the  cavity. 

Fig.  64. — This  radiograph  shows  the  case,  illustrated  in  Fig.  63,  immediately  after 
the  surgical  operation.  In  excising  the  root,  the  end  dropped  into  the  deep  Hngual 
pocket  where  it  was  difficult  to  find  and  remove  (see  a) .  The  radiograph  aided  materially, 
as  it  verified  the  presence  of  the  root-end  and  its  location. 

is  required  to  evacuate  the  pus.  In  treating  these  conditions  it  is 
essential  to  explore  the  affected  area,  using  a  sharp  steel  instrument 
in  order  to  determine  whether  there  is  caries  or  necrosis.  Unless 
too  much  bone  is  involved,  the  case  can  be  successfully  treated  by 
first  making  a  liberal  opening  with  a  sharp  bistoury  and,  if  necessary, 
breaking  down  the  sharp  edges  of  bone,  through  which  the  pus 
has  burrowed,  with  a  round  bur  having  a  long  shank,  after  which  the 
sinus  should  be  estabhshed  in  the  usual  manner,  using  a  considerable 
quantity  of  the  bland  solution.  Now  dry  the  canal  and  force 
through  the  sinus  full  strength  phenolsulphonic  acid.  Sometimes 
it  is  advisable  to  place  a  piece  of  blotting-paper  soaked  in  liquid 
petroleum  over  the  lingual  opening  when  forcing  the  acid  through. 


CHRONIC    ALVEOLAR   AESCESS 


381 


This  causes  the  agent  to  spread  and  come  in  contact  with  the  entire 
area  involved.  Alcohol  and  the  oils  will  neutralize  any  excess  of 
the  phenolsulphonic  acid  that  may  get  on  the  other  tissues  of  the 
mouth.  This  treatment  should  be  repeated  as  often  as  the  case 
demands.  When  there  is  no  evidence  of  pus  and  the  case  has  healed 
sufi&ciently  so  that  there  is  only  a  watery  discharge,  the  root  can  be 
filled. 

7.  Secondary  Abscess  Pocket. — Occasionally  we  find  an  abscess 
of  the  discharging  variety  which  does  not  yield  to  our  general  treat- 
ment, yet  we  are  reasonably  certain  that  none  of  the  complications 
so  far  mentioned  are  present.  In  these  cases  we  can  suspect  a  sec- 
ondary abscess  pocket.  This  is  especially  true  where  the  sinus  opened 
into  the  mouth  several  -teeth  removed  from  the  affected  tooth. 
This  pocket  can  usually  be  discovered  by  the  aid  of  a  small  silver 
probe.     The  treatment  is  simple — all  that  is  necessary  is  to  open  the 


Fig.  65. — This  radiograph  shows  the  involvement  of  the  upper  left  central  and 
lateral  incisors,  with  a  common  sinus.  Both  teeth  carried  perfectly-adjusted  porcelain 
crowns.  The  radiograph  not  only  shows  the  involvement  of  both  teeth,  but  also 
shows  that  the  roots  are  properly  filled.  The  treatment  here  is  purely  surgical  and 
means  the  curettement  of  the  affected  area. 


pocket,  wash  it  out  first  with  a  bland  solution,  then  inject  phenol- 
sulphonic acid.  In  using  phenolsulphonic  acid  in  such  cases  it  can- 
not be  injected  through  the  tooth,  therefore  it  is  necessary  to  use  a 
syringe — a  glass  syringe  with  an  asbestos-packed  plunger  and  a  gold 
or  a  platinum  needle. 

8.  Involving  Two  or  More  Teeth. — It  is  not  an  uncommon 
thing  to  find  two  or  more  teeth  involved  with  a  common  sinus. 
Such  a  case  is  illustrated  in  Fig.  65.  This  figure  also  shows  the 
importance  of  radiography  in  the  diagnosis  of  these  complicated  ab- 
sent conditions.  Here  it  would  be  impossible  to  cure  the  disease  by 
simply  treating  either  one  of  the  aft'ected  teeth.     In  this  particular 


382  PRACTICAL   DENTAL   THERAPEUTICS 

case,  the  root-canal  of  both  teeth  having  been  properly  filled, 
external  curettement  is  the  treatment  indicated. 

9.  Involving  Antrum. — The  pus  in  making  -its  exit  follows  the 
line  of  least  resistance,  and  sometimes  it  is  easier  to  work  its  way 
through  the  floor  of  the  antrum  than  through  the  labial  or  Hngual 
plate  of  bone.  The  treatment  of  this  compHcation  is  of  sufficient 
importance  to  merit  discussion  by  itself,  and  will  be  considered 
later;  but  in  this  connection  it  is  well  to  remember  that  so  good  an 
authority  as  Kyle,  viewing  the  question  from  the  nasal  side,  finds  that 
fully  50  per  cent,  of  antral  diseases  are  of  dental  origin. 

Periapical  Cysts. — Cysts  are  quite  frequently  associated  with 
pulpless  teeth  in  which  are  abscesses  which  have  passed  through  the 
acute  stage.  Logan  was,  perhaps,  one  of  the  first  to  direct  attention 
to  the  presence  of  cysts  in  connection  with  pulpless  teeth.  Surgery 
is  the  treatment  indicated.  The  area  involved  must  be  thoroughly 
curetted  and  the  part  packed  until  granulation  fills  the  space. 

SURGICAL  TREATMENT  OF  CHRONIC  ALVEOLAR  ABSCESSES  AND 

THEIR  SEQUELS 

In  all  complicated  abscesses  which  do  not  yield  to  medicinal 
treatment  as  outHned  in  the  preceding  pages,  we  can  often  save  the 
affected  tooth  and  make  it  healthy  and  useful  by  adopting  surgical 
methods.  Thorough  curettement  of  the  area  involved  and,  if  neces- 
sary, excision  of  the  root-end  will  save  many  teeth,  such  as  have  been 
too  frequently  lost  in  the  past  by  extraction.  Many  dentists  have 
preferred  to  extract  the  tooth  in  these  complicated  cases  rather  than 
undertake  to  effect  a  cure  by  means  of  surgery.  It  is  because  of  this 
fact,  and  with  the  hope  of  stimulating  a  greater  interest  in  this  phase 
of  the  subject,  that  the  author  includes  herein  a  description  of  his 
method  of  treating  these  cases. 

Indications  for  Surgery. — Surgical  treatment  is  indicated  in 
those  cases  where  medicinal  treatment  has  failed  to  effect  a  cure, 
or  where  the  root-canal  has  been  thoroughly  filled  and  the  abscess 
develops  subsequently.  Especially  is  surgery  indicated  in  this  latter 
class  of  cases,  if  the  affected  tooth-root  is  firm  in  the  jaw  and  has  a 
good  natural  crown  or  carries  a  well-adjusted  artificial  crown.  It  is 
always  best,  where  practicable,  to  have  a  radiograph  taken  to  aid  in 
determining  the  area  involved  and  whether  or  not  the  root-canal  has 
been  properly  fiJled. 

In  those  cases  of  failure  to  cure  by  treatment  through  the  canal, 
and  where  surgery  is  to  be  undertaken,  the  author  advises  filling  the 


CHRONIC   ALVEOLAR   ABSCESS  383 

canal,  using  gutta-percha  for  the  purpose,  before  operating,  especially 
if  the  root-end  is  to  be  excised;  for,  while  it  can  be  done,  it  is  rather 
difficult  to  close  the  generally  large  apical  opening  of  the  root  after 
excision. 

This  operation  should  be  done  under  the  most  aseptic  conditions; 
the  hands  of  the  operator  and  assistant,  the  site  of  operation,  as  well 
as  all  instruments  used  should  be  sterilized;  and,  in  the  absence  of  a 
radiograph,  a  thorough  exploration  should  be  made  before  operating  so 
that  the  amount  of  process  and  root  involved  may  be  noted.  The 
instruments  used  here  were  selected  for  the  purpose  from  the  surgical 
supply  houses,  and  some  of  them  have  been  modified  by  the  author  to 
better  meet  our  demands.  They  are  all-metal  instruments  and  can 
be  sterilized  by  boihng. 

The  Anesthetic. — The  success  of  the  operation  will  depend 
entirely  upon  the  thoroughness  with  which  it  is  done.  It  is,  therefore, 
highly  essential  that  the  patient  be  assured  that  the  operation  not 
only  can  but  will  be  performed  with  very  little  pain.  This  will  be 
interesting  to  the  patient  and  will  increase  his  confidence  in  the 
operator.  It  is  unnecessary  to  administer  a  general  anesthetic,  as 
the  area  can  be  completely  anesthetized  by  the  proper  use  of  local 
anesthetics.  Either  infiltration  or  conductive  anesthesia  may  be 
employed,  as  the  operator  deems  best.  The  author  generally  uses 
the  infiltration  method.  With  a  strong  all-metal  syringe,  the  healthy 
tissue  on  either  side  of  the  abscess  area  is  infiltrated  with  the  solu- 
tion, two  injections  being  made  on  the  labial  or  buccal  and  one  on  the 
lingual,  if  the  abscess  is  discharging  labially,  and  the  reverse  if  dis- 
charging hngually.  If  pressure  is  made  over  the  point  of  the  needle 
with  the  forefinger  of  the  left  hand  as  the  solution  is  being  injected,  only 
a  small  amount  of  the  solution  will  be  necessary  to  thoroughly  anesthe- 
tize the  part.  It  is  essential  that  the  area  be  completely  anesthe- 
tized; for  we  have  assured  our  patient  that  there  would  be  practically 
no  pain,  and  if  this  assurance  is  carried  out,  we  are  more  likely  to 
do  our  work  so  thoroughly  that  there  will  be  no  question  as  to  the 
ultimate  success  of  the  operation.  It  is  but  natural  that  most  opera- 
tors should  do  their  work  more  thoroughly  when  the  factor  of  pain  is 
eliminated.  The  author  desires  to  speak  plainly  on  this  point;  for  it 
will  be  far  better  for  all  concerned  not  to  undertake  the  operation  than 
to  fail  to  do  it  with  that  degree  of  thoroughness  which  means  success. 

The  Incision  and  Control  of  Hemorrhage.^When  the  part  is 
anesthetized  and  only  one  tooth  is  involved,  a  vertical  incision  is  made 
about  one-half  or  three-quarters  of  an  inch  in  length,  directly  over 
the  affected  root.     In  case  two  teeth  are  involved,  it  is  necessary  to 


384 


PRACTICAL   DENTAL   THEEAPEUTICS 


make  a  circular  incision.  A  bistoury,  such  as  is  illustrated  in  Fig.  66, 
is  used,  and  care  should  be  taken  to  make  the  incision  as  high  as 
possible  (if  the  case  is  an  upper  tooth) ,  stopping  it  about  on  a  line 
with  the  floor  of  the  necrotic  area.  If  the  incision  is  made  any 
lower  than  this,  the  healthy  process  is  likely  to  be  left  exposed,  when 
it  is  more  difl&cult  for  the  tissues  to  close  over  this  part.     After  the 


Fig.  66. 

incision  is  made,  and  sponged  to  check  the  primary  hemorrhage,  a 
flat  bone  chisel  (Fig.  67),  used  as  a  periosteotome,  is  employed  to 
separate  the  periosteum  from  the  bone  for  about  one-fourth  inch  on 
either  side  of  the  incision.  The  part  is  again  sponged  and  a  tissue 
retractor  (Fig.  68)  is  firmly  adjusted  (see  also  Figs.  69  and  70). 
The  arms  of  the  retractor  can  be  spread  so  that  the  soft  tissues  over- 


FlG.  67. 

lying  the  bone  can  be  held  back,  and  at  the  same  time  the  pressure 
produced  controls  the  hemorrhage  from  this  source.  There  is  a  great 
difference  in  the  resihency  of  the  soft  tissues,  and  with  some  patients 
the  resihency  is  soon  overcome  by  the  pressure  of  the  retractor,  in 
which  case  the  retractor  vdW.  loosen.  To  overcome  the  difficulty  in 
such  cases,  the  author  has  had  made  a  spring  retractor  which  may 


Fig.  68. 


Fig.  68a. 


be  used.  The  operation  from  now  on  should  be  practically  blood- 
less; especially  is  this  true  if  adrenalin  chlorid  is  added  to  the 
local  anesthetic,  as  should  always  be  done.  One  minim  (0.06  mil) 
of  a  1—1,000  adrenaUn  chlorid  solution  added  to  30  min.  (2.0  mils) 
of  the  local  anesthetic  solution  is  about  the  right  proportion. 


Fig.  69. — This  picture  shows  a  case  where  the  abscess  had  not  been  treated. 
Therapeutics  alone  will  not  cure  such  a  case,  surgery  being  indicated. 


Fig,  70. — The  same  case  as  illustrated  in  Fig.  69  after  the  canal  had  been  properly 
treated  and  filled.     The  retractor  is  adjusted  ready  for  the  root-end  resection. 


CHRONIC   ALVEOLAR   ABSCESS 


385 


Exposing  the  Area  Involved. — We  now  have  the  alveolar  process 
over  the  root-end  exposed  to  view,  unless  this  has  been  destroyed  by 
the  necrotic  process,  which  is  frequently  the  case.  Where  it  has  not 
been  destroyed,  it  is  removed  by  means  of  bone  chisels  and  mallet. 
The  latter  is  shown  in  Fig.  71.  The  use  of  chisels  and  mallet  was 
suggested  to  the  author  by  Shamberg,  of  New  York.  The  flat  chisel 
is  used  across  the  lower  part  of  the  opening  and  along  either  side,  by 
the  claws  of  the  retractor.  To  chisel  across  the  upper  part  of  the 
opening,  a  half-round  chisel  is  used  (Fig.  72).  Many  patients  do 
not  like  the  malleting  process  of  removing  bone.     While  it  is  not 


Fig.  71. 

necessarily  painful,  if  the  part  has  been  thoroughly  anesthetized, 
nevertheless  it  is  not  pleasant.  To  overcome  this  feature,  the 
author  has  had  heavier  chisels  and  curettes  made  by  means  of  which 
the  bone  may  be  removed  by  hand  pressure.  The  loosened  bone  is 
then  removed  when  the  root-end  and  area  involved  should  be  ex- 
posed to  view.  We  are  now  able  to  make  an  ocular  examination 
and  determine  whether  the  case  simply  needs  curettement  or  whether 
the  root-end  should  also  be  excised.  If  the  necrotic  area  extends 
below  the  apex  of  the  root,  it  is  always  best  to  excise  as  much  of  the 


MiiiJiiiigiiiJiMiiiiiiM 


Fig.  72. 


latter  as  is  involved,  to  make  sure  that  healthy  bone  is  reached  on 
either  side.  It  makes  no  difference  whether  the  end  of  the  root  is 
left  flat,  round,  or  slanting,  as  long  as  healthy  bone  is  reached. 

Before  excising  the  end,  it  is  best  to  drill  on  either  side  with  a 
fissure  bur.  If  this  is  done,  the  root-end,  after  excision,  can  be  easily 
removed  with  an  ordinary  pair  of  pliers.  The  exposed  end  can  now 
be  excised  with  sharp  fissure  or  cross-cut  burs.  Several  such  burs 
should  be  in  readiness  as  they  soon  clog  in  a  wet  field.  The  opera- 
tion of  excising  the  root-ends  of  teeth  is  known  as  apicoectomy  or 
apexotomy. 

25 


386  PRACTICAL    DENTAL    THERAPEUTICS 

Curetting  the  Area.- — After  removing  the  excised  root-end,  which 
as  stated  above  is  an  easy  matter,  the  remaining  end  of  root  should 
be  made  smooth,  using  a  large  round  bur  for  the  purpose.  The 
affected  area  is  now  thoroughly  curetted,  removing  any  carious  or 
necrosed  bone.  Here  bone  curettes  of  varying  sizes  (Figs.  73,  74 
and  75)  are  employed.     This  is  the  only  part  of  the  entire  operation 


which  may  be  at  all  painful,  and  the  patient  should  now  be  so  in- 
formed. Even  here  the  curetting  can  be  done  with  very  Uttle  pain,  if 
the  anesthetic  has  been  injected  lingually  as  mentioned. 

Filling  End  of  Root. — The  process  of  filling  the  end  of  the  root 
with  amalgam  has  been  suggested  by  Lucas,  Henshaw,  and  others. 
Copper  cement  has  also  been  suggested  for  the  purpose.     The  author 


Fig.  74. 

has  followed  these  suggestions  in  a  few  instances  with  seemingly  good 
results;  but  he  is  of  the  opinion  that  a  good  sterile  gutta-percha  root- 
filling,  recently  inserted,  will  prove  more  compatible  with  the  tis- 
sues. It  is  the  safest  practice,  therefore,  always  to  retreat  and  refill 
the  canals  of  such  teeth  previous  to  performing  the  surgical  opera- 
tion.    Even  though  the  radiograph  indicates  that  the  canal  has  been 


Fig.  75- 

filled  to  the  end,  in  these  long-standing  cases  we  have  no  assurance 
that  the  root-filHng  was  inserted  under  aseptic  conditions  or  that  the 
canal  is  sterile. 

Washing  and  Packing  the  "Wound. — With  the  end  of  the  root 
smooth  and  cut  down  to  healthy  process  on  either  side,  the  area 
thoroughly  curetted,  the  wound  should  now  be  washed  with  a  warm 
antiseptic  solution.  This  may  be  done  without  removing^the  re- 
tractor.    Following  the  washing  process,  the  moisture  should  be 


CHRONIC   ALVEOLAR   ABSCESS 


387 


absorbed  and  the  wound  packed  with  sterile  gauze,  saturated  with 
euroform  paste.  The  orthoform  in  this  paste  will  absolutely  control 
the  pain  which  nearly  always  follows  the  use  of  local  anesthetics* and 
the  cutting  of  bone,  while  the  europhen,  giving  off  iodin,  will  stimulate 


Fig.  76.  Fig.  77. 

Fig.  76.— This  radiograph  shows  a  long-standing  abscess  on  an  upper  left  lateral. 
The  root  had  been  filled  with  lead.  The  dark  line  is  a  silver  probe  which  was  placed 
in  the  sinus  while  radiograph  was  being  taken. 

FiG._  77. — This  shows  the  same  case  the  day  after  the  root-end  was  excised.  The 
pocket  is  now  ready  to  be  filled  with  bismuth  paste. 


Fig.  78.  Fig.  79. 

FiG.  78. — This  radiograph  shows  a  chronic  alveolar  abscess  on  an  upper  right 
central.     The  canal  was  filled  and  the  root  carried  a  good  porcelain  crown. 

Fig.  79. — This  shows  the  same  case  four  days  after  excision  of  the  denuded  root- 
end  and  the  curettement  of  the  afi'ected  area. 


the  cells  and  hasten  granulation;  the  oleoaginous  vehicle  (liquid 
petroleum)  keeps  the  saliva,  laden  with  bacteria,  out  of  the  wound. 
Subsequent  Treatment. — The  patient  should  be  instructed  to 
keep  the  mouth  as  clean  as  possible  by  using  an  antiseptic  mouth- 
wash; and  after  the  initial  packing,  which  should  be  left  only  twenty- 


388 


PRACTICAL    DENTAL    THERAPEUTICS 


four  hours,  bismuth  paste  is  injected  every  few  days  until  granulation 
fills  the  cavity  with  healthy  tissue. 

Radiographs  showing  cases  in  the  author's  practice,  before  and 
after  treatment,  are  illustrated  in  Figs.  76,  77,  78  and  79.  See  also 
Fig.  80  and  Figs.  85  and  86.     In  those  cases  where  the  lingual  plate 


Fig.  80. — This  radiograph  shows  an  abscess  which  developed  on  the  distal  root  of 
a  lower  molar,  after  the  mesial  root  had  been  pre\'iously  excised  and  a  bridge  adjusted. 
Thorough  curettement  and  keeping  the  pocket  filled  with  bismuth  paste  cured  the 
condition.  The  abscess  was  of  the  pericemental  variety,  and  was  doubtless  caused  by 
injury  to  the  alveolar  process  and  pericemental  membrane,  produced  in  the  removal 
of  the  excised  mesial  root. 

of  bone  has  been  destroyed  and  a  deep  pocket  is  present,  or  where 
the  abscess  involves  the  antrum,  care  should  be  taken  that  the  root- 
end,  when  excised,  does  not  drop  into  the  deep  pocket  or  antral 
cavity,  as  it  is  often  difficult  to  locate  and  remove.     Such  a  case  is 


Fig.  81.  Fig.  82. 

Fig.  81. — This  shows  a  tumor  which  developed  in  the  apical  area  of  a  central  incisor 
which  carried  a  Richmond  crown.     The  tooth  had  been  improperly  treated. 

Fig.  82. — This  shows  a  central  incisor  carrjdng  a  Richmond  crown.  Pink  gutta- 
percha can  be  seen  in  the  apex  of  the  original  (A,)  showing  that  the  root  was  perfectly 
filled  at  first;  but  in  driUing  for  the  dowel  subsequently  the  dentist  punctured  the  root, 
afterward  forcing  gutta-percha  through  the  puncture  (5).  An  abscess  developed, 
doubtless  from  lack  of  asepsis. 

illustrated  on  p.  380  in  Fig.  64.  It  is  a  good  plan  in  such  cases  to 
drill  a  small  hole  through  the  end  of  the  root  through  which  a  small 
wire  may  be  inserted  and  bent  to  form  a  hook.  Then,  when  the 
root-end  is  excised,  it  can  be  easily  removed  \nth.  the  wire  without 
danger  of  being  lost. 


CHRONIC  ALVEOLAR    ABSCESS 


389 


Other  complications  are  illustrated  in  Figs.  81  to  84. 

Whenever  the  operator  is  in  doubt  as  to  the  best  means  of  treating 
complicated  alveolar  abscesses,  he  should  not  hesitate  to  consult 
with  a  practitioner  who  has  had  more  experience  in  treating  these 
cases.    Such  a  course  cannot  be  construed  as  evidence  of  lack  of  knowl- 


FiG.  83.  Fig.  84. 

Fig.  83. — This  radiograph  illustrates  a  case  where  three  of  the  lower  incisors  con- 
tained dead  pulps,  causing  an  abscess  with  a  common  sinus  which  opened  externally 
under  the  chin,  just  to  the  right  of  the  median  line.  The  dentist  had  been  treating  the 
abscess  by  washing  through  the  left  central  only  and  sinus,  finallj^  filling  the  root.  The 
case  failing  to  heal  after  several  months'  treatment,  the  patient  was  referred.  The 
radiograph  shows,  as  stated,  that  the  right  central  and  lateral  were  also  involved.  By 
sterilizing  the  contents  of  the  canals  of  these  teeth  and  forcing  phenolsulphonic  acid 
through  the  sinus,  the  case  seemed  to  heal.  It  was  necessary,  howeverj  to  operate  and 
curette  the  area. 

Pig.  84  shows  the  external  sinus  before  treatment. 


Fig.  85.  Fig.  86. 

Fig.  85. — This  abscessed  tooth  was  treated  and  the  canal  filled  in  Nov.,  1911, 
when  radiograph  was  taken.  As  might  have  been  expected  the  sinus  did  not  heal. 
Apicoectomy  was  performed  Dec.  11,  191 1. 

Pig.  86. — This  picture  shows  the  same  case  and  was  taken  Mar.  21,  1914.  The 
tooth  is  solid  in  the  jaw  and  perfectly  comfortable. 

edge,  but  of  conservatism  and  progress.  The  foci  of  infection  about 
the  teeth,  as  in  all  other  parts  of  the  body,  must  he  removed.  We 
should  not  let  the  extraction  of  a  tooth,  or  any  number  of  teeth, 
stand  in  our  way  in  accomplishing  this  end ;  but  the  author's  cHnical 
experience  leads  him  to  the  belief  that  many  good  men  to-day  are 


390  PRACTICAL   DENTAL   THERAPEUTICS 

unnecessarily  advising  the  extraction  of  teeth  as  the  only  means  of 
eliminating  focal  infection  in  the  mouth.  Both  dentists  and  physi- 
cians have  sadly  neglected  this  phase  of  practice  in  the  past,  for  lack 
of  knowledge  of  the  results  of  such  practice.  Much  good  work  is 
being  done  along  this  line  at  the  present  time  in  the  research  insti- 
tutions of  both  the  dental  and  medical  professions;  and  the  future 
will  bring  a  solution  of  the  many  problems  involved.  In  the  mean- 
time dentists  must  continue  to  do  their  best,  which,  it  must  be  admit- 
ted, is  very  good. 

TREATMENT  OF  GANGRENOUS  PULPS  AND  ABSCESSES  n^ 
DECroUOUS  TEETH 

In  treating  the  conditions  under  consideration  in  the  mouths  of 
children,  it  is  necessary  in  most  cases  to  modify  our  usual  method  of 
treatment.  Our  first  duty  here  is  to  gain  the  confidence  of  the  child. 
If  the  abscess  is  associated  with  a  deciduous  molar  which  we  would 
desire  to  save  for  at  least  a  year  or  two,  it  can  be  treated  nicely  in  the 
following  manner:  After  gaining  the  confidence  of  the  little  patient 
the  mouth  can  be  rinsed  with  an  antiseptic  solution — one  which  has  a 
pleasant  taste.  Then  open  into  the  pulp  chamber  and  place  a  pledget 
of  cotton  in  the  opening.  Now  mix  on  one  end  of  the  cement  slab 
thymoHzed  calcium  phosphate  and  the  formocresol  remedy,  making 
a  stiff  paste.  On  the  other  end  of  the  slab  have  a  quick-setting  ce- 
ment ready  to  mix.  Again  rinse  the  patient's  mouth  and,  keeping 
the  cavity  as  dry  as  possible,  gently  pack  the  paste  into  the  pulp 
chamber  and  flow  the  cement  over  it,  filhng  the  cavity.  It  is  re- 
markable how  rapidly  these  abscesses  will  heal  and  remain  quiet 
when  treated  in  this  manner,  provided,  of  course,  there  be  no  caries  or 
necrosis  of  bone,  which  condition  is  rarely  found  in  the  mouths  of  chil- 
dren as  the  result  of  abscess  from  deciduous  teeth.  If  it  is  desirable 
to  keep  the  tooth  in  the  patient's  mouth  for  more  than  a  year,  it  is 
better  to  neutralize  the  putrescence  with  formocresol  as  usual,  .when 
the  root-canals  can  be  flooded  with  chloroform  and  eucapercha  com- 
pound, and  the  entire  cavity  filled  with  gutta-percha.  The  gutta- 
percha filling,  if  properly  inserted,  will  last  as  long  as  is  necessary 
to  save  the  tooth,  even  in  occlusal  cavities  where  it  is  exposed  to  the 
stress  of  mastication. 


PERICEMEXT.\L  ABSCESS 
GENERAL  CONSmERATIONS 

All  of  the  alveolar  abscesses  which  we  have  discussed  thus  far 
have  been  the  result  of  an  infection  in  the  periapical  area,  the  infection 
being  due  to  pathogenic  bacteria,  poisonous  ptomains  and  irritating 
gases,  which  have  escaped  from  a  gangrenous  root-canal.  There  is, 
however,  an  abscess  that  occurs  in  the  alveolar  region  about  the  roots 
of  teeth,  and  is  not  due  to  the  causes  mentioned.  This  particular 
kind  of  abscess  occurs  in  connection  with  Hve  teeth;  not  necessarily 
so,  however.  There  is  a  progressive  breaking  down  of  the  perice- 
mental membrane,  which  in  dental  Hterature  is  called  a  pericemental 
abscess.  The  origin  of  this  particular  kind  of  abscess  is  rather  vague ; 
but  it  is  generally  supposed  to  be  due  to  some  traumatic  injury,  the 
infection  being  blood-born  or  hematogenous.  It  frequently  occurs 
on  the  mesial,  labial  or  distal  surface  of  the  roots  of  the  anterior 
teeth  involving  most  of  the  surface.  The  Hngual  surface  of  these 
teeth  is  seldom  involved.  It  has  also  been  known  to  occur  be- 
tween the  roots  of  molar  teeth,  especially  upper  molars.  It  may 
discharge  through  a  sinus  near  the  apical  end  of  the  roots  or  at  the 
gum  margin ;  in  the  latter  case  it  resembles  a  pyorrheal  pocket. 

THERAPEUTICS 

For  convenience  in  outHning  our  treatment  for  a  pericemental 
abscess,  the  condition  may  be  classified  as  acute  and  chronic.  As  a 
rule,  there  is  very  little  pain  associated  with  either  variety  of  perice- 
mental abscess.  In  the  acute  form,  which,  as  such,  is  extremely 
difl&cult  to  diagnose,  the  patient  will  complain  of  "something  being 
wrong  with  a  particular  tooth."  About  all  that  can  be  done  thera- 
peutically with  the  acute  form  is  to  pacify  the  patient,  as  best  we  can, 
until  the  acute  abscess  develops  into  the  chronic  variety,  when  pus 
is  formed  and  discharges  and  a  sinus  is  estabhshed ;  thus  the  diag- 
nosis is  more  easily  made.  In  those  cases  where  the  sinus  opens  on 
the  labial  or  buccal  surface  of  the  gum  and  not  at  the  gum  margin, 
care  should  be  exercised  in  the  diagnosis  so  as  not  to  confuse  the  con- 
dition with  an  abscess  of  the  ordinary  variety,  and  open  into  \ital 
teeth.  A  case  where  an  incorrect  diagnosis  was  made  is  illustrated  in 
Fig.  87. 

391 


392 


PRACTICAL   DENTAL   THERAPEUTICS 


If  the  abscess  occurs  on  the  anterior  teeth  where  the  area  in- 
volved can  be  curetted  and  cauterized,  it  will  generally  yield  to  the 
treatment;  but  the  treatment  of  a  chronic  pericemental  abscess  on 
molar  teeth  is  at  best  a  discouraging  procedure.  If  it  is  possible  to 
thoroughly  curette  the  area  the  tooth  can  be  saved,  provided  the 
surrounding  surfaces  are  kept  clean.  In  those  cases  where  the 
area  can  be  reached,  an  opening,  if  necessary,  can  be  made  through 
the  gum,  the  root  thoroughly  scraped  and  poHshed;  then,  after  wash- 
ing out  the  abscessed  area,  it  should  be  cauterized  with  some  cauter- 
izing agent.     Nothing  gives  better  results  than  phenolsulphonic  acid 


Fig.  87. — This  radiograph  partially  shows  the  result  of  an  incorrect  diagnosis, 
where  a  pericemental  abscess  was  mistaken  for  an  alveolar  abscess.  The  abscess 
occurred  between  the  roots  of  the  upper  right  central  and  lateral  incisors  with  a  sinus 
opening  on  the  labial  midway  between  the  gum  margin  and  the  apex  of  the  central 
incisor.  The  case  gave  a  history  of  having  received  a  blow  on  these  two  teeth  about 
two  months  previous.  The  dentist,  thinking  the  pulp  in  the  central' was  dead,  de- 
liberately opened  into  the  vital  tooth.  The  patient  then  went  to  another  dentist  who 
attempted  to  remove  the  pulp  by  pressure  anesthesia.  It  was  difficult  to  anesthetize 
and  a  remnant  was  left  in  the  apical  area.  Acute  pericementitis  followed  and  nitrous 
oxid  and  oxygen  were  administered  and  the  remnant  removed.  This  only  aggravated 
the  pericemental  trouble;  the  cavity  was  left  unsealed  and  the  crown  of  the  tooth  became 
dark  blue  in  color.  The  patient  was  now  referred.  Two  treatments  of  phenol  com- 
pound cured  the  pericementitis,  when  the  root  was  filled.  Subsequently  the  tissue 
about  the  abscess  was  anesthetized,  the  area  curetted,  and  the  wound  packed  for 
twenty-four  hours  with  sterile  gauze  saturated  with  euroform  paste.  Two  subsequent 
injections  of  bismuth  paste  cured  the  case;  after  which  the  color  of  the  tooth  was  re- 
stored by  sealing  caustic  pyrozone  in  the  cavity,  when  a  gold  inlay  was  inserted.  The 
patient  in  this  instance  was  a  lady,  and  when  we  recall  that  the  tooth  involved  was 
an  anterior  one,  the  seriousness  of  the  mistaken  diagnosis  becomes  all  the  more  apparent. 


With  a  proper  glass  syringe  and  a  gold  or  platinum  needle,  the  remedy 
can  be  injected  into  the  abscess  pocket.  One  thorough  treatment 
should  effect  a  cure.  In  curetting  these  cases  it  is  far  better  to  go  a 
little  beyond  the  affected  territory  rather  than  fail  to  remove  all  of 
the  affected  tissue  and  have  the  abscess  recur.  Where  the  abscess 
can  be  reached,  thorough  curettement  and  cauterization  will  effect 
a  cure.  That  portion  of  the  pericemental  membrane  which  has  been 
destroyed  will,  perhaps,  never  be  regenerated,  but  if  we  succeed  in 


PERICEMENTAL   ABSCESS 


393 


having  granulations  fill  in  the  area  involved,  even  though  the  mem- 
brane is  not  regenerated  over  that  particular  surface  of  the  root,  the 
tooth  can  be  saved  for  a  considerable  length  of  time.  (See  Figs.  88 
and  89.) 


Fig.  89. 

Fig.  88. — This  radiograph  shows  a  pericemental  abscess  on  the  distal  root  of  a 
lower  first  molar.  The  patient,  a  lady,  has  a  perfect  set  of  teeth  and  gums  healthy, 
except  this  area.  The  part  was  anesthetized  vnth  a  local  anesthetic,  the  gum  lanced 
freely  on  the  buccal,  the  root  scaled  and  area  curetted.  The  exposed  root  being  hyper- 
sensitive was  subsequently  cauterized  with  silver  nitrate.  The  abscess  3aelded  to 
the  treatment.  The  cause  of  this  particular  abscess  was  a  wooden  toothpick  having 
been  broken  off  between  the  teeth. 

Fig.  89. — The  case  illustrated  in  Fig.  88  was  treated  in  April,  1916.  This  radio- 
graph was  taken  Jan.  i6,  191 7.  Notice  the  bone  regeneration  between  the  roots  and 
the  absence  of  deposits  which  show  plainly  in  the  negative  for  Fig.  88.  The  tissues 
around  the  tooth  are  as  healthy  as  though  no  infection  had  ever  been  present,  and 
there  is  very  little  depression  of  the  soft  tissues  between  the  first  and  second  molars. 


Fig.  90. — A  case  sirhilar  to  that  illustrated  in  Fig.  88,  in  the  mouth  of  a  male 
patient.     Treated  in  the  same  manner,  with  a  good^  result. 


FILLIXG  ROOT-CAN.\LS 

GENERAL  CONSIDERATIONS 

The  operation  of  filling  root-canals  stands  as  a  sort  of  dividing 
line  between  the  subjects  of  Therapeutics  and  Operative  Dentistry 
proper.  There  has  been  a  great  variance  of  opinion  in  the  past 
regarding  the  methods  and  materials  used  for  this  purpose.  The 
method  employed  in  this  operation  depends  largely  upon  the  mate- 
rials which  the  individual  operator  uses,  and  a  great  variety  of 
materials  have  been  suggested  and  used,  among  which  the  following 
may  be  mentioned: 

1.  Cotton. — Saturating  it  with  such  antiseptics  as  creosote, 
iodoform,  etc. 

2 .  Zinc  Oxychlorid  Cement. — Chemically  pure  zinc  oxid  (powder) 
and  a  saturated  solution  of  zinc  chlorid  (liquid).  Some  operators 
advise  fiUing  the  apex  with  soft  gold  and  the  canal  proper  with  the 
cement. 

3.  Paraffin. — Using  the  material  alone  or  in  combination  \^^th 
such  agents  as  bismuth  oxid,  etc. 

4.  Medicated  Pastes. — A  variety  of  such  pastes  have  been  used, 
the  powder  for  which  consists  of  zinc  oxid  as  the  base  with  thymol, 
alum,  chinosol,  etc.,  in  varying  proportions;  the  Hquid  containing 
formaldehyd  in  solutions  of  different  strength  in  such  Hquid  drugs 
as  phenol,  cresol,  creosote,  etc. 

5.  Gutta-Percha. — Using  the  material  in  solution  in  such  solvents 
as  chloroform,  eucal>^tol,  and  oil  of  cajuput.  In  connection  with  the 
gutta-percha  solution,  gutta-percha  points,  gold,  copper  and  lead 
wire,  etc.,  have  been  employed. 

In  the  Hght  of  our  knowledge  to-day  of  focal  infection,  it  would 
be  fortunate  indeed  if  it  could  be  correctly  stated  that  all  of  the 
materials  above  mentioned,  except  gutta-percha,  had  been  discarded; 
for  all,  with  the  one  exception,  have  been  tried  and  found  wanting. 
The  radiograph  has  proved  the  correctness  of  this  statement. 

In  the  opinion  of  the  author,  which  is  shared  by  men  Hke  Rhein, 
Black,  Callahan,  and  others,  gutta-percha,  modified  and  used  in  such 
a  manner  as  to  best  meet  the  needs  of  the  individual  operator,  is  the 
only  material  at  our  command  to-day  upon  which  reliance  may  be 
placed.     From  experiments  made.  Price  is  even  skeptical  regarding 

3Q4 


FILLING    ROOT-CAXALS 


395 


gutta-percha  on  account  of  its  inherent  tendency  to  shrink;  but 
against  his  laboratory  experiments  stands  the  record  of  thousands  of 
clinical  cases  which  proves  conclusively  that  this  material,  properly 
used,  answers  our  every  purpose  for  jiUing  the  canals  of  pulpless 
teeth.  This  being  true,  the  proposition  resolves  itself  into  the 
problem  of  determining  the  best  method  of  modifying  and  using  the 
material. 

We  may  modify  the  properties  of  gutta-percha  by  incorporating 
-s^-ithin  its  substance  certain  drugs;  and  drugs  are  added  to  root- 
filling  materials  for  two  purposes:  One  a  pharmaco-mechanical 
reason;  the  other  on  a  therapeutic  basis.     In  the  case  of  gutta-percha, 


Fig.  91. — These  teeth  were  treated  and  the  canals  filled  in  November  and  December, 
1902.  The  radiograph  was  taken  Apr.  3,  1916,  over  fourteen  years  after  the  three  teeth 
had  been  treated.  While  there  is  no  infection  at  the  end  of  the  roots,  though  noneof 
the  canals  is  well  tilled,  this  is  an  exception  to  the  rule  and  will  not  excuse  any  dentist  for 
not  filling  the  canals  of  teeth  to-day  better  than  they  have  been  filled  in  the  past.  _  Xotice 
the  mental  foramen  between  the  bicuspids.  ]\Iany  times  this  appears  in  a  radiograph 
near  the  end  of  a  bicuspid  root,  and  may  be  mistaken  for  a  "rarefied  area."  The  in- 
ferior dental  canal  may  also  show  near  the  end  of  a  lower  molar  (see  the  distal  root 
of  Fig.  42) . 

it  is  admissible  to  add  to  and  use  in  connection  ^-ith  the  material  such 
drugs  as  chloroform  and  eucal}^tol,  for  pharmacal  and  mechanical 
purposes.  In  the  opinion  of  Callahan,  even  rosin  may  be  added  on 
this  basis.  The  solvents,  chloroform  and  eucah-ptol,  soften  the 
material  which  permits  its  adaptation,  by  proper  manipulation  vdth 
heat  and  instruments,  to  every  irregularity  in  the  canal  which  has 
been  cleaned  and  opened  by  the  previous  treatment — thus  the  latter 
is  completely  filled  with  a  nonabsorbable,  and,  if  properly  manipu- 
lated, I  believe,  nonshrinkable  material. 

Whether  or  not  we  are  justified  in  adding  drugs  to  root-filling 
materials  to-day  for  therapeutic  purposes  is  a  debatable  question. 
Speaking  of  the  use  of  the  many  so-called  "permanently  antiseptic" 
root-filling  pastes  of  various  kinds  that  have  been  advocated  and 
used,  Best  says:^   "The  only  possible  excuse  I  can  see  for  the  use  of 

^  Dental  Items  of  Interest,  July,  1015,  page  50S. 


396  PRACTICAL   DENTAL   THERAPEUTICS 

these  preparations  in  the  roots  of  teeth  is  that  the  operator  knows  he 
has  left  something  in  the  root  which  he  should  not  have  left;  and  in- 
stead of  remo\dng  it,  he  places  his  'life-saver'  in  Qn  top  of  it  and  then 
rests  assured  he  'will  have  no  trouble'  from  it  in  the  future."  When 
we  remember  that  to  which  I  have  repeatedly  directed  attention, 
viz.,  there  is  no  such  thing  as  a  permanently  antiseptic  root-filling 
material,  we  cannot  rightfully  have  this  satisfying  assurance.  That 
gutta-percha  aseptically  introduced  in  an  aseptic  canal  will  remain 
aseptic  for  years  is  the  firm  belief  of  the  author  and  others,  based  upon 
years  of  clinical  experience  and  observation.  We  have  no  right  to  fill 
a  canal  of  a  tooth  which  requires  an  antiseptic,  as  such,  in  our  filling 
material.  Referring  again  to  Best,  he  makes  the  statement "  that  the 
only  solution  lies  in  an  almost  entire  nondependence  upon  antiseptics 
in  canal  fillings  and  in  the  maintaining  of  asepsis  in  the  operation." 
I  fully  agree  with  the  first  part  of  the  statement  that  we  should  not 
depend  upon  antiseptics,  as  such,  in  our  root-filling  material;  but  I 
firmly  believe  in  the  liberal  and  generous  use  of  antiseptics,  and  in  the 
careful  and  intelligent  use  of  disinfectants,  in  establishing  and  main- 
taining asepsis  in  treating  pulpless  teeth  and  preparing  the  canals  for 
filling. 

Precautions. — It  will  be  remembered  that  three  factors  were 
emphasized  under  the  Removal  of  Pulps  and  the  Subsequent  Treat- 
ment, viz.: 

1.  Establish  and  maintain  asepsis. 

2.  Preserve  the  color  of  the  tooth. 

3.  Thoroughly  fill  the  canal. 

The  author  suggests  filling  all  canals,  for  reasons  previously  mentioned, 
with  gutta-percha  in  the  manner  which  will  be  subsequently.described. 
In  connection  with  the  preservation  of  the  color  of  the  tooth,  it 
should  be  mentioned  that  white  base  plate  gutta-percha  should  be 
used,  especially  for  the  purpose  of  dissolving  in  eucalyptol,  making 
eucapercha.  If  this  white  substance  is  forced  into  the  tubuli  of  the 
crown  of  the  tooth,  as  it  is  liable  to  be,  it  will  not  change  the  color  of 
the  tooth-structure  as  woiild  the  pink  gutta-percha.  A  great  many 
dentists  have  been  moistening  the  canal,  previous  to  filling  with  gutta- 
percha, with  oil  of  eucalpytus;  and,  as  a  result,  much  unnecessary 
pericementitis  has  followed  this  operation.  If  oil  of  eucalyptus  is 
used  at  all,  the  refined  oil  only  should  be  selected;  and  far  more  satis- 
factory results  will  follow  the  use  of  eucalyptol,  the  most  volatile  con- 
stituent of  oil  of  eucalyptus.  While  eucalyptol  is  irritating,  it  is  not 
nearly  so  much  so  as  is  oil  of  eucalyptus.     The  author  suggests  modi- 


FILLING   ROOT-CANALS  397 

fying  the  irritating  property  of  eucalyptol  and  enhancing  its  anti- 
septic power  by  combining  menthol  and  thymol,  as  suggested  in  the 
prescription  of  eucalyptol  compound  in  the  discussion  of  Nonseptic 
Pericementitis  (p.  360).  In  this  proportion,  the  agents  added 
do  not  interfere  with  the  solvent  power  of  eucalyptol  for  gutta-percha; 
but  if  the  amounts  are  increased  to  any  appreciable  extent,  this  does 
not  hold  true.  Oil  of  cajuput  has  also  been  used  for  moistening 
the  canal;  but  it  has  no  advantage  since  its  constituent,  cineol,  is 
chemically  identical  with  eucalyptol. 

In  filling  root-canals  it  is  always  the  safest  practice  to  adjust  the 
rubber  dam, /or  asepsis  must  be  established  and  maintained.  The  same 
agents  may  be  used  for  sterilizing  the  teeth  after  the  dam  is  adjusted 
as  were  described  in  removing  pulps  by  the  Anesthetization  Method. 
The  canals  should  be  aseptic  before  the  operation  is  attempted.  If 
there  is  any  doubt  in  this  regard,  the  operation  should  be  deferred 
until  they  are  in  such  a  condition.  Not  o*nly  should  the  canals  be 
sterile;  but  all  instruments  and  material  should  be  germ  free.  Meth- 
ods of  accomplishing  this  end  were  considered  under  Dental  Sterili- 
zation (p.  277).  The  instruments  may  be  sterilized  by  moist  heat, 
the  cotton  wrapped  on  broaches,  and  other  such  material  may  be  steril- 
ized by  dry  heat;  but  it  is  necessary  to  rely  upon  chemic  agents  for 
sterilizing  the  gutta-percha  points.  The  latter  should  always  be 
sterilized  when  first  purchased  by  immersion  for  a  few  hours  in  modi- 
fied alcohol  or  other  suitable  disinfecting  solutions,  when  they  may  be 
removed  and  placed  on  sterile  gauze  to  absorb  the  liquid,  thus  dried 
and  put  in  gelatin  capsules,  Petri  dishes,  or  other  sterile  containers. 
Even  with  this  method  of  keeping  the  points,  it  is  well  to  place  them 
in  modified  alcohol  a  few  minutes  before  they  are  used.  Though  it 
may  be  done,  it  is  impracticable  to  sterilize  the  hands  and  keep  them 
germ  free  throughout  the  operation;  and  it  is  not  necessary  to  have 
them  absolutely  sterile,  if  the  cotton  on  the  broaches  was  sterilized 
by  dry  heat  after  being  wrapped,  as  first  suggested  by  Best.  This  is 
the  safest  practice. 

If  the  author's  suggestion  has  been  followed  in  regard  to  using 
eucalyptol  compound  for  the  final  dressing  in  treating  pulpless  teeth, 
the  canal  will  generally  be  in  condition  to  fill,  so  far  as  moisture  is  con- 
cerned, when  the  dressing  is  removed.  Black  states^  that  "moisture 
is  effectively  removed  by  flooding  the  canals  previous  to  filling  with 
eucalyptol  or  oil  of  cajuput.  The  oils  have  a  greater  ajQS.nity,  or 
attraction,  for  the  dentin  than  has  the  moisture,  therefore,  displace 
it. "     If  testing  with  sterile  cotton  or  an  absorbent  point  indicates 

^  Special  Dental  Pathology,  p.  328. 


398  PRACTICAL   DENTAL   THERAPEUTICS 

moisture  in  the  apical  end,  it  should  be  absorbed  before  attempting 
to  fill  the  canal.  Overdrying  with  heated  air  or  instruments  should 
be  avoided. 

Filling  Large  Canals. — In  filling  large  canals,  especially  those  in 
connection  with  which  dental  granulomas  or  alveolar  abscesses  have 
been  treated,  where  the  apex  is  large  and  where  we  ought  not  to  ex- 
pect to  get  a  response  from  the  patient  when  the  gutta-percha  cone 
reaches  the  apex,  on  account  of  the  loss  of  tissue  in  the  periapical 
area,  it  is  best  to  measure  the  canal  and  then  use  one  cone  which 
approximately  fits  it  rather  than  use  two  or  three  smaller  cones  with 
the  possibility  of  unnecessarily  forcing  one  through  the  apex  and  into 
the  periapical  area.  To  measure  the  canals,  cotton  may  be  tightly 
wrapped  around  a  smooth,  sterile  broach  and  inserted.  When  after 
repeated  trials  the  cotton  fits  the  canal,  a  cone  should  be  selected 
which  is  slightly  smaller  than  the  tightly  wrapped  cotton.  The  canal 
should  now  be  moistened  with  chloroform,  then  a  small  amount  of 
eucapercha  introduced,  the  latter  being  worked  up  or  down  into  the 
canal  with  a  fine  smooth  broach,  exhausting  the  air.  If  cotton  is 
wrapped  around  the  broach  used  for  this  latter  purpose,  only  a  few 
shreds  should  be  used;  for  we  should  avoid  making  a  piston  out  of  the 
broach  and  thus  defeat  our  object  of  exhausting  the  air.  This 
accompHshed,  the  selected  cone,  flattened  on  the  large  end,  should 
be  dipped  in  chloroform  and  placed  in  the  canal;  when  it  should  be 
worked  up  and  down  a  few  times  with  a  slight  pumping  motion.  In 
this  manner  the  chloroform  and  eucapercha  soften  the  outer  sur- 
face of  the  cone,  leaving  the  central  portion  with  sufficient  resistance 
to  cause  the  mass  of  gutta-percha  to  spread  laterally  as  the  cone  is 
finally  pressed  to  place  with  the  phers.  Root-canal  pluggers  may  now 
be  used  and  the  mass  of  gutta-percha  firmly  packed  in  the  canal.  If 
chloroform  is  used,  very  Httle  heat  is  required  to  soften  the  cones. 
The  final  packing  may  be  done  with  a  tampon  of  cotton  or  Japanese 
bibulous  paper  saturated  with  chloroform,  as  suggested  by  Rhein. 
In  filling  large  canals  from  which  five  pulps  have  recently  been  re- 
moved, the  patient  will  generally  flinch  before  the  cone  reaches  the 
apex.  When  this  occurs,  we  should  wait  a  few  minutes,  when  the 
cone  can  be  gently  pressed  much  farther  without  causing  the  patient 
to  flinch  a  second  time.  If  these  precautions  are  observed,  they  will 
be  the  means  of  preventing  much  of  the  pericementitis  following  the 
filHng  of  root-canals. 

We  should  make  every  endeavor  to  have  our  sterile  root-filling 
reach  at  least  to  the  end  of  the  root;  and  Rhein  has  repeatedly 
emphasized  the  necessity  of  encapsulating  the  apical  end  of  the  root 


FILLING   ROOT-CANALS  399 

with  the  fluid  gutta-percha,  in  all  cases  where  gangrenous  canals  had 
been  treated  which  in  any  way  involved  the  periapical  tissues.  The 
author  believes  the  future  will  prove  this  to  be  necessary  in  cases 
where  dead  and  infected  pulps  have  been  treated.  In  clean  cases  it 
is  not  necessary  for  the  filling  material  to  protrude  beyond  the  apex, 
though  it  is  difficult  to  fill  canals  as  they  must  be  filled  for  success 
without  ha\dng  the  material  pass  through  the  apex  to  a  greater  or  less 
extent.     Fortunately  the  tissues  take  kindly  to  sterile  gutta-percha. 

Filling  Small  Canals. — In  filHng  all  canals  where  we  can  enter 
nicely  with  a  small  canal  plugger,  it  is  best  to  follow  the  technic  out- 
lined above,  using  a  cone  which  mil  enter  the  canal.  However 
much  we  may  regret  it,  there  are  canals,  especially  in  molar  teeth,  so 
small  and  tortuous  that  only  a  fine,  smooth  broach  will  enter,  at  least 
to  any  depth.  It  is  useless  to  try  to  fill  such  canals  with  a  gutta-percha 
cone.  The  methods  of  enlarging  the  canal  by  the  use  of  acids  and 
caustics,  as  referred  to  in  connection  with  the  destruction  of  pulp 
tissue  in  such  canals,  can  be  employed;  but  it  is  not  always  advisable 
to  enlarge  them  sufficiently  to  admit  a  cone  of  any  appreciable  size, 
and  there  is  no  resistance  to  a  very  small  cone,  especially  after  it  has 
been  softened  with  solvents  or  heat.  After  the  larger  canal  or  canals 
in  a  multi-rooted  tooth  are  filled  in  the  ordinary  manner,  the  smaller 
ones  can  be  moistened  with  chloroform  and  eucapercha  and  the  solu- 
tion worked  up  or  down  into  the  canal.  This  process  should  be  kept 
up  for  some  time  until  the  chloroform  evaporates,  leaving  the  gutta- 
percha rather  thick  and  quite  plastic.  The  sides  of  the  pulp  chamber 
can  now  be  moistened  with  eucalyptol  compound  and  a  piece  of  base 
plate  gutta-percha,  selected  and  softened  in  the  flame,  can  be  packed 
into  the  pulp  chamber,  when  pressure  can  be  made  toward  the  small 
canals  and  the  plastic  gutta-percha  forced  into  them.  This  is  much 
better  practice  than  simply  ffiling  the  mouth  of  the  canal  with  a 
gutta-percha  cone,  leaving  the  rest  of  the  canal  empty.  If  the  canal 
is  so  small  and  tortuous  that  even  a  small  broach  will  not  enter,  and  if 
it  cannot  be  enlarged  by  the  use  of  acids  or  caustics,  as  referred  to 
previously,  it  will  be  necessary  either  to  extract  the  tooth,  or  record  the 
fact  and  occasionally  check  up  on  the  case  with  a  radiograph  to  ascer- 
tain if  any  infection  is  present  at  the  end  of  the  root.  In  every  case 
where  it  can  be  done,  the  gutta-percha  in  the  canals  should  be  pro- 
tected by  zinc  oxychlorid  cement  (see  Fig.  92).  This  may  be  done 
in  all  cases  except  those  where  it  is  necessary  to  subsequently  insert 
a  post  in  the  canal  for  some  purpose. 

The  technic  of  filling  root-canals  with  gutta-percha,  as  described 
by  difi'erent  operators,  varies  slightly,  as,  for  instance,  in  the  drugs 


400  PRACTICAL   DENTAL   THERAPEUTICS 

used  as  solvents  and  in  the  manner  of  introducing  and  packing  the 
material  in  the  canal.  Some  operators  believe  they  can  get  a  more 
compact  mass  of  gutta-percha  in  the  canal  by  cutting  the  points  and 
introducing  them  in  small  pieces.  Whatever  method  is  employed, 
the  gutta-percha  must  be  left  firmly  packed  in  the  canal;  and  it  is  the 
duty  of  every  dentist  to  use  this  material  in  filling  root-canals  accord- 
ing to  the  method  which  in  his  hands  offers  the  greatest  opportunity 
for  success.  The  operation  is  one  that  requires  attention  to  detail, 
and,  while  the  author  does  not  believe  it  necessary  to  radiograph  every 
root-filling,  a  sufficient  number  should  be  radiographed  until  the 
operator  is  satisfied  he  has  mastered  the  technic  of  the  method  em- 
ployed. All  difficult  cases  and  questionable  root-fillings  should  be 
radiographed.  If  in  treating  pulpless  teeth,  preparing  the  canals 
for  filling,  and  in  root-filling  operations,  the  dentist  always  tries 
to  do  his  best,  he  will  be  rewarded  by  finding  that  the  radiograph 
will  prove  his  best  is  very  good. 

Callahan's  Rosin  Solution. — A  discussion  of  filling  root-canals 
would  not  be  complete  without  mention  of  Callahan's  rosin  solution. 
The  formula  follows: 

I^ — Resinae,  gr.  xii  (0.75  Gm.) 

Chloroformi,  fl.  5iii  (12.0  mils) — M. 

Sig. — Use  as  directed. 

In  directing  attention  to  the  method  of  using  this  solution  Calla- 
han says:^  "Most  of  us  at  some  time  or  other  have  shared  in  the 
opinion  that  it  mattered  but  little  what  material  was  used  in  filling 
root-canals.  It  does  matter  as  to  the  material;  it  does  matter  as  to 
the  manner  of  placing  the  material  in  the  canal.  The  matter  of 
prime  importance  is  the  sealing  of  the  more  or  less  numerous  foramina, 
and,  as  we  have  no  assurance  that  all  of  the  foramina  in  a  given  root- 
canal  are  located  near  the  apex,  it  becomes  our  duty  to  seal  the  whole 
of  each  canal  with  a  material  that  will  search  out  and  seal  minute 
canals  or  openings  which,  owing  to  physical  conditions,  we  are  unable 
to  see." 

Technic. — After  desiccating  the  canal,  observing  strict  asepsis, 
the  latter  is  flooded  with  the  thin  rosin  solution,  purnping  it  up  or 
down  into  the  canal.  When  the  latter  is  full  of  the  solution,  the  air 
is  exhausted  by  passing  a  fine  wire  or  broach  to  the  end.  A  gutta-per- 
cha cone  which  reaches  to  or  near  the  end  is  selected  and  gently  placed 
about  halfway  within  the  canal ;  the  cone  is  pumped  up  and  down, 
from  forty  to  sixty  times,  and,  as  it  dissolves  in  the  chloroform,  it  is 

^  Dental  Items  of  Interest,  1915,  p.  585. 


FILLING   ROOT-CANALS  4OI 

advanced  farther  toward  the  apex.  This  pumping  motion  forces  the 
rosin  solution,  according  to  Callahan,  into  every  opening,  seaHng  all 
tubuli  and  foramina  that  have  been  opened  in  the  preparation  of  the 
canal  for  filling.  If  this  does  not  leave  the  large  end  of  the  gutta- 
percha cone  at  or  near  the  mouth  of  the  canal,  a  smaller  cone  may  be 
placed  and  packed  into  the  mass  v*Tith  cold  root-canal  pluggers,  using 
warm  air  to  soften  the  protruding  gutta-percha,  if  necessary.  This 
packing  forces  the  semifluid  chloropercha  and  rosin  into  the  unknown 
canals  and  pockets,  and,  at  the  same  time,  brings  the  surplus  chloro- 
percha to  the  mouth  of  the  canal,  where  it  may  be  removed  with 
cotton. 

The  author  can  see  no  advantage  in  the  addition  of  rosin,  for  the 
chloroform  solution  will  only  enter  the  tubuli  as  far  as  moisture  has 
been  removed.  It  is  difficult  in  the  mouth  to  deplete  the  tooth- 
structure  of  its  moisture,  and,  were  it  possible,  it  is  questionable 
whether  it  ought  to  be  done.  Then,  too,  if  we  are  justified  in  follow- 
ing Rhein,  as  I  beheve  we  are  where  the  periapical  tissues  have  been 
involved  in  the  infection,  it  surely  is  best  to  attempt  to  encapsulate 
the  end  with  bland  gutta-percha,  rather  than  have  a  substance  Like 
rosin  incorporated  with  the  material. 


26 


DISCOLORED  TEETH 
GENERAL  CONSIDERATIONS 

In  the  discussion  of  the  methods  of  removing  pulps  from  teeth 
and  the  subsequent  treatment,  the  treating  of  gangrenous  pulps 
and  the  various  kinds  of  alveolar  abscesses,  the  author  endeavored 
to  emphasize  the  necessity  of  preserving  or  restoring  the  color  oj  the 
tooth.  There  is,  perhaps,  nothing  more  annoying  to  a  conscientious 
dentist  and  to  an  appreciative  patient  than  a  discolored  tooth  in  the 
patient's  mouth.  If  the  precautions,  which  have  been  mentioned 
throughout  this  work  with  reference  to  this  factor,  are  observed  in  the 
treatment  of  teeth,  the  necessity  for  bleaching  may  often  be  avoided ; 
for,  after  all  that  has  been  written  on  this  subject  is  studied,  it  must  be 
admitted  that  the  most  successful  method  of  bleaching  teeth  is  to  so 
treat  them  that  they  will  not  need  to  be  bleached. 

Sources  of  Discoloration. — There  are  three  principal  sources  of  the 
discoloration  of  tooth-structure,  viz., 

1.  Pulp  decomposition. 

2.  Remedial  agents. 

3.  Metallic  fillings. 

The  most  common  source  is  that  of  pulp  decomposition.  Many 
teeth  containing  gangrenous  pulps  are  discolored  before  the  patient 
presents  for  treatment.  In  those  cases  where  the  color  is  not  lost  the 
gangrenous  conditions  can  be  corrected  and  the  color  preserved  by  the 
method  of  treatment  outlined  under  Gangrenous  Pulps. 

Occasionally,  however,  teeth  have  been  observed  to  assume  a 
pinkish  hue  shortly  after  some  traumatic  injury,  rapid  regulation,  or 
after  some  irritating  drug  had  been  appHed  to  a  small  exposure  of 
the  pulp,  as,  for  instance,  arsenic  trioxid.  Kirk  has  offered  us  a 
very  plausible  explanation  of  this  immediate  discoloration.  He 
says:  "It  is  now  known  that  the  pink  staining  of  the  tooth  is  brought 
about  by  a  rupture  of  the  stroma  of  the  red  blood  disks  Hberating 
their  contained  hemoglobin,  which  dissolves  in  the  plasma,  forniing 
a  solution  of  hemoglobin  which  readily  penetrates  the  dentinal  tubuli, 
the  lumen  of  which  is  of  insufficient  diameter  to  admit  the  unbroken 
red  corpuscle.  This  pink  discoloration  resulting  from  the  infiltra- 
tion of  hemoglobin  solution  represents  the  first  stage  of  tooth  dis- 

402 


DISCOLORED    TEETH 


403 


coloration.  The  pink  stain  readily  undergoes  alterations,  later  on 
assuming  a  brownish  tint,  due  to  the  breaking  down  of  the  highly 
complex  molecule  of  hemoglobin  into  a  reduced  product  known  as 
hematin." 

Maimer  of  Discoloration. — There  are  two  ways  by  which  the 
discoloration  is  produced,  i.e.,  by  solutions  which  stain  the  cement- 
Hke  substance  uniting  the  tubuli  and  by  the  ingress  into  the  tubuli  of 
insoluble  coloring  substances.     For  instance,  many  remedial  agents 
in  solution,  such  as  oil  of  cassia,  silver  nitrate,  etc.,  have  the  property 
of  staining  the  cementing  substance  and  producing  discolorations; 
while  the  sulphids  formed  from  certain  metals,  as,  for  example,  in 
amalgam  filHngs,  produce  discoloration  by  virtue  of  being  forced 
into  the  tubular  structure  of  the  dentin.     If,    in    the    treatment 
of   teeth,   more  care   were  taken  to  select  remedial  agents  which 
would  not  stain  the  tooth-structure,  and  if  high-grade  alloys  were 
selected  in  making  amalgam  fillings,  the  cavity  properly  prepared, 
amalgam  inserted  and  polished  when  set,  there  would  be  few  teeth 
discolored  from  these  causes.     But,  as  has  been  stated,  many  teeth 
containing  gangrenous  pulps  are  discolored  before  the  patient  pre- 
sents for   treatment;   and,   inasmuch  as   this  is  by  far   the  most 
common  source,  it  is  well  to  try  to  ascertain  definitely  the  true 
cause  of  these  discolorations;  for  it  is  difficult  and  unsatisfactory  to 
try  to  bleach  a  tooth  when  we  have  no  knowledge  of  the  nature  of  the 
pigment  we  are  trying  to  bleach.^ 

Principle  of  Bleaching. — The  principle  which  governs  the  suc- 
cessful bleaching  of  teeth  is  to  chemically  change  the  molecule  of  the 
pigment  in  such  a  manner  as  to  destroy  its  color,  or  chemically  change 
the  insoluble  coloring  substance  to  a  soluble  form,  when  it  can  be 
washed  out  of  the  tooth-structure. 

Important  Factors. — When  a  case  presents  for  bleaching  there  are 
three  important  factors  to  be  determined: 

1.  Ascertain,  if  possible,  the  cause  of  the  discoloration. 

2.  Decide  whether  or  not  the  color  can  be  successfully  restored. 

3.  The  selection  of  the  proper  bleaching  agent  with  which  to  re- 
store the  color. 

The  general  cause  of  the  discoloration  can  usually  be  ascertained 
from  the  history  of  the  case  as  related  by  the  patient.  Whether  or 
not  the  tooth  can  be  successfully  bleached  depends  largely  upon  the 

1  The  author  has  explained  the  chemistry  of  tooth-discoloration  from  pulp  decom- 
position in  Johnson's  "Text-book  of  Operative  Dentistry"  and  in  various  dental 
journals. 


404  PRACTICAL   DENTAL    THERAPEUTICS 

cause  of  the  discoloration,  the  condition  of  the  tooth-structure,  and 
the  length  of  time  the  tooth  has  been  discolored.  Experience  will 
prove  that  the  teeth  which  will  permanently  retain  their  color,  after 
it  is  restored,  are  those  that  have  a  good  bulk  of  dentin,  which 
dentin  can  be  protected  by  the  remaining  enamel  and  some  filling 
material,  preferably  porcelain  if  this  material  is  at  all  indicated.  I 
desire  to  emphasize  the  fact  that  it  is  folly  to  expect  a  tooth  to  retain 
its  color  any  length  of  time  after  once  being  bleached,  unless  the  dentin 
is  properly  protected. 

Ha\'ing  ascertained  the  cause  of  the  discoloration  and  believing 
that  the  condition  of  the  tooth-structure  justifies  us  in  attempting  to 
bleach  the  tooth,  we  come  to  the  most  important  consideration,  viz., 
the  selection  of  the  bleaching  agent  with  which  the  color  can  be  re- 
stored with  the  least  inconvenience  to  the  patient  and  operator. 

METHODS  OF  BLEACHING 

All  of  the  methods  employed  in  bleaching  teeth  involve  more  or 
less  chemistry  and  from  a  chemic  vieA\'point  there  are  two  general 
methods  of  bleaching  teeth — oxidation  and  reduction. 

I.  Oxidation.- — This  general  method  is  of  two  kinds  also,  direct 
and  indirect. 

1.  Direct. — By  direct  oxidation  is  meant  the  use  of  any  agent  or 
agents  from  which  oxygen  can  be  directly  obtained.  The  agents 
used  for  the  purpose  are : 

Sodium  dioxid,  XaoOa- 

Twenty-five  per  cent,  ethereal  solution  of  hydrogen  dioxid,  H2O2. 
Alphozone.  (COOH.CH2.CH2CO)20o. 
Acetozone,  CeHsCO.O.O.COCHs. 

Aluminum  chlorid.  AkCle.  and  a  3  per  cent,  aqueous  solution  of 
hydrogen  dioxid. 

Oxalic  acid,  H2C2O4. 

2.  Indirect. — By  indirect  oxidation  is  meant  the  use  of  any  agent 
or  agents  by  which  oxygen  can  be  obtained  indirectly.  The  agents 
employed  are  such  as  will  liberate  nascent  chlorin,  CI,  a  chemically 
active  gas,  which,  in  the  presence  of  moistures,  seizes  upon  a  molecule 
of  water,  H2O,  abstracts  the  atoms  of  hydrogen,  H,  forming  hydro- 
chloric acid,  HCl,  and  liberates  the  oxygen,  0,  in  the  nascent 
state,  as  H2O  -|-  2CI  =  2HCI  +  0  (nascent; . 

Some  of  the  agents  used  for  this  purpose  are: 

Aluminum  chlorid  and  a  freshly  prepared  Labarraque's  solution 
(Harlan). 


DISCOLORED    TEETH 


405 


Chlorinated  lime  and  dilute  acetic  acid  (Truman). 

Powdered  alum,  Al2K2(S04)4,  and  Labarraque's  solution. 

Solution  of  sodium  chlorid  electrically  decomposed. 

II.  Reduction. — By  reduction  is  meant  the  use  of  any  agent  or 
agents  which  will  abstract  oxygen  from  a  compound  containing  it. 
The  agents  which  have  been- Recommended  are  sodium  sulphite, 
Na2S03,  10  parts,  and  boric  acid,  H3BO3,  7  parts.  These  are  mixed 
and  placed  within  the  tooth,  moistened  with  water  and  hermetically 
sealed  (Kirk).  A  reaction  occurs  between  the  two  substances,  with 
the  ultimate  formation  of  sulphurous  acid  which  has  a  great  afiSnity 
for  oxygen  and  is,  therefore,  a  good  reducing  agent.  In  some  cases 
where  the  tooth  has  been  discolored  by  remedial  agents,  and  where  it 
is  desired  to  break  up  the  color  molecule,  good  results  are  obtained  by 
this  method.  Whenever  the  method  is  used,  the  tooth  should  subse- 
quently be  thoroughly  washed  with  an  alkaline  solution,  such  as  a  10 
per  cent,  solution  of  sodium  bicarbonate  or  borax,  to  neutralize  the 
acid. 

In  most  cases  of  discoloration,  the  direct  oxidation  method  is  pref- 
erable; and,  in  view  of  the  fact  that  all  of  the  agents  used  in  the  indi- 
rect method  of  bleaching  depend  upon  the  generation  of  oxygen  for 
their  efficacy,  it  can  readily  be  understood  that  the  direct  method  is 
far  more  satisfactory.  The  fact,  also,  that  hydrochloric  acid  is  a 
constant  by-product  in  the  indirect  method,  thereby  creating  an  acid 
medium,  adds  to  the  objectionable  features  of  this  method;  for  manu- 
facturers have  recognized  for  years  that  better  results  can  be  ob- 
tained in  bleaching  ivory,  wool,  hair,  feathers,  etc.,  when  the  bleach- 
ing process  is  carried  on  in  an  alkaline  medium.  This  is  likewise  true 
in  bleaching  teeth.  Believing,  then,  that  the  direct  oxidation  method 
is  far  superior  to  the  indirect,  I  shall  not  burden  my  readers  by 
describing  the  latter  method,  but  will  direct  attention  to  the  de- 
tailed use  of  sodium  dioxid  and  25  per  cent,  ethereal  solution  of 
hydrogen  dioxid — both  direct  oxidizing  agents,  which,  if  their  chemic 
properties  are  known  and  their  dental  application  understood,  the 
author  believes  to  be  the  best  agents  for  bleaching  teeth  thus  far 
suggested  to  the  profession. 

Using  Sodium  Dioxid.- — Sodium  dioxid  occurs  in  commerce  as  a 
yellow  powder  and  is  readily  decomposed  by  water  into  caustic  soda 
and  oxygen.  Because  of  this  latter  fact,  much  of  the  product  obtained 
from  wholesale  druggists  labeled  "sodium  dioxid,"  is  nothing  but 
caustic  soda.  This  accounts  for  the  fact  that  many  dentists  have 
tried  this  method  of  bleaching  and  failed  to  get  results.  The  fault  is 
not  with  the  method,  but  with  the  powder  used.     In  order  that  we 


4o6  PRACTICAL    DENTAL    THERAPEUTICS 

might  be  able  to  ascertain  the  efficacy  of  the  chemical,  some  years 
ago  I  devised  a  simple  chemic  test  for  this  purpose.  In  a  clean,  dry 
test-tube  place  about  15  gr.  (i.o  Gm.)  of  the  powder  and  to  it  add  30 
min.  (2.0  mils)  of  water.  If  the  specimen  is  good  sodium  dioxid, 
enough  oxygen  should  be  generated  to  kindle  a  glowing  spHnter  held 
at  the  mouth  of  the  tube.  Having  tested  the  chemical  and  proved 
it  to  be  sodium  dioxid,  and  not  caustic  soda,  the  next  thing  is  to  prop- 
erly prepare  the  tooth,  which,  of  course,  should  have  been  previously 
treated  and  the  root  filled  with  white  gutta-percha. 

Preparation  of  the  Tooth.' — The  rubber  dam  should  be  adjusted, 
if  possible,  without  the  use  of  the  steel  clamp.  The  ligature  should  be 
wrapped  twice  around  each  tooth  included  in  the  dam,  which  should 
be  at  least  two  teeth  on  either  side  of  the  one  to  be  bleached.  This 
will  prevent  the  by-product,  caustic  soda,  from  getting  on  the  soft 
tissue  and  destroying  it.  The  lower  third  of  the  root-filUng  should 
now  be  removed  with  a  good-sized  round  bur — it  being  necessary,  for 
permanent  results,  to  bleach  the  tooth  rootwise  as  far  as  possible. 
We  are  now  ready  to  apply  our  bleaching  agent. 

Making  the  Application. — Both  the  dry  sodium  dioxid  and  a 
solution  made  by  carefully  dusting  the  powder  into  ice-water  are  rec- 
ommended to  be  used.  The  best  results  are  obtained  by  using  the 
dry  powder,  placing  it  in  the  cavity  and,  with  a  platinum  broach  or 
pointed  glass  instrument,  working  the  powder  well  up  into  the  canal 
from  which  the  root- filling  has  been  removed.  Care  should  be  taken 
not  to  use  steel  instruments,  as  oxygen  will  attack  the  steel,  forming 
ferric  oxid,  and,  therefore,  we  may  get  into  the  tooth  the  pigment  we 
are  trying  to  remove.  In  some  cases  it  is  rather  difficult  to  place  the 
powder  in  the  cavity  without  getting  it  on  the  patient's  face  or  cloth- 
ing. To  overcome  this  a  strip  of  unannealed  i  :  1,000  platinum  foil 
can  be  placed  between  the  discolored  and  adjacent  tooth,  letting  it 
extend  above  or  below  the  cutting-edge,  as  the  case  may  be,  when 
white  base  plate  gutta-percha  can  be  warmed  and  pressed  against  the 
lingual  surfaces  of  the  teeth  included  in  the  dam.  This  forms  a 
pocket  on  the  labial  side  within  which  the  powder  can  be  easily  placed, 
.  using  a  little  gold  or  platinum  spoon  or  spatula.  In  more  difficult 
cases  a  paste  can  be  made  of  the  powder  and  chloroform,  in  which  it 
is  insoluble,  quickly  packing  the  paste  into  the  cavity,  evaporating  the 
chloroform,  and  leaving  the  dry  powder  where  it  is  desired.  Distilled 
water  is  now  dropped  upon  the  powder,  causing  a  Hvely  effervescence 
and  the  following  reaction  takes  place : 

Na202  +  H2O  =  2NaOH  +  0  {nascent). 


DISCOLORED    TEETH  407 

This  nascent  oxygen  is  a  powerful  oxidizing  agent.  It  attacks  and 
rapidly  destroys  any  organic  matter  which  may  be  present  in  the 
tubular  structure  of  the  dentin.  It  also  thoroughly  bleaches  vege- 
table colors  and  acts  upon  any  iron  compounds  which  may  have  pro- 
duced the  discoloration.  It  converts  ferric  hydroxid,  if  present,  into 
ferric  oxid — still  an  insoluble  compound.  If  ferrous  sulphid  is  pres- 
ent in  the  moist  state,  it  may  be  converted  into  ferrous  sulphate,  a 
soluble  salt;  but  in  the  presence  of  caustic  soda  it  would  be  reprecip- 
itated  as  ferrous  hydroxid,  which,  in  turn,  in  the  presence  of  oxygen,  is 
at  once  reconverted  into  ferric  oxid.  Therefore,  the  pigment  to  be 
removed,  if  our  chemic  reasoning  is  correct  as  to  the  cause  of  the  dis- 
coloration from  pulp  decomposition,  is  ferric  oxid,  an  insoluble  com- 
pound, and  it  must  be  removed  mechanically  by  washing  the  tooth. 
Its  removal  is  faciHtated  by  the  by-product,  caustic  soda,  acting 
upon  any  fatty  substances — fat  being  an  end-product  of  the  putre- 
faction of  the  proteid  material — which  may  be  present  in  the  tubuli. 
The  result  of  this  action  is  a  soluble  soap,  the  removal  of  which  by 
washing  aids,  as  stated,  the  mechanical  removal  of  the  insoluble 
pigment. 

It  is  the  opinion  of  the  author  that  the  ultimate  success  depends 
quite  as  much  upon  the  mechanical  removal  of  the  coloring  matter 
as  upon  its  chemic  destruction,  therefore  the  necessity  of  thor- 
oughly washing  the  tooth  after  each  appHcation  of  the  bleaching 
agent.  Warm  distilled  water  should  be  used  in  a  strong  syringe, 
letting  a  moist  sponge  absorb  the  water.  The  cavity  is  now  dried, 
the  color  of  the  tooth  observed  and  the  process  repeated,  if  necessary. 
Usually  two  or  three  appHcations  are  sufficient.  If  the  color  is  not 
readily  restored,  the  dentin  can  be  saturated  with  a  2  per  cent,  solu- 
tion of  sulphuric  acid  which  now  enters  the  tubuh  and  chemically 
converts  the  oxids,  that  may  not  have  been  mechanically  or  otherwise 
removed  by  the  saponifying  and  washing  process,  into  sulphates. 
The  salts  produced  are  freely  soluble,  and  can  readily  be  washed  out 
by  again  using  the  warm  water. 

Final  Treatment. — When  the  tooth  is  satisfactorily  bleached,  a 
paste  of  precipitated  calcium  phosphate  and  distilled  water  can  be 
placed  in  the  cavity,  packed  into  the  lower  third  of  the  root  and 
burnished,  with  a  warm  burnisher,  against  all  exposed  dentin.  This 
is  thoroughly  dried  by  burnishing,  the  excess  removed,  and  a  light- 
colored,  quick-setting  cement  used  to  form  a  base  for  the  final  filling. 

Using  25  per  cent.  Ethereal  Solution  of  Hydrogen  Dioxid. — A 
2  5  per  cent,  ethereal  solution  of  hydrogen  dioxid,  called  also  caustic 
pyrozone,  can  be  obtained  in  specially  prepared  and  hermetically 


4o8  PRACTICAL   DENTAL   THERAPEUTICS 

sealed  glass  tubes.  The  date  of  its  preparation  is  stamped  upon  the 
tube  to  guarantee  its  activity,  for  its  value  as  a  bleaching  agent  de- 
pends upon  the  volume  of  nascent  oxygen  which  is  liberated.  It  is, 
therefore,  important  that  a  good  specimen  of  the  agent  be  obtained. 
Care  must  be  exercised  in  opening  the  tube,  which  should  be  wrapped 
in  a  cold,  wet  towel  and  held  firmly  in  the  left  hand.  With  a  sharp 
file  make  a  groove  around  the  pointed  end  of  the  tube,  after  which  this 
end  may  be  easily  broken  with  a  pair  of  pliers,  the  tube  being  pointed 
away  from  the  face.  A  sharp  file  should  be  used,  as  a  dull  one  might 
produce  a  spark  and  cause  an  explosion.  When  the  tube  is  opened  the 
contents  should  be  transferred  at  once  to  a  clean  glass-stoppered 
bottle.  The  stopper  should  be  sealed  with  parafiin  when  the  remedy 
is  not  being  used.  In  making  the  transfer,  care  should  be  taken  to 
keep  the  agent  from  coming  in  contact  with  the  fingers,  as  it  readily 
cauterizes  soft  tissue. 

Preparation  of  the  Tooth. — The  tooth  should  be  prepared  exactly 
as  in  using  sodium  dioxid,  except  that  the  cavity  of  the  tooth  should 
be  moistened  with  an  alkaline  solution  (lo  per  cent,  solution  of  borax 
or  sodium  bicarbonate)  before  making  the  application.  This  is  done 
in  recognition  of  the  fact  that  the  bleaching  process  is  more  successful 
if  carried  on  in  an  alkaline  medium. 

Making  the  Application. — There  are  some  cavities  within  which  it 
is  difficult  to  place  sodium  dioxid,  even  if  a  paste  has  been  made  with 
chloroform,  on  account  of  the  rapid  evaporation  of  the  latter.  This  is 
especially  true  where  the  cavity  is  small  and  in  the  lingual  surface  of 
one  of  the  six  upper  anterior  teeth.  Teeth  containing  such  cavities 
can  usually  be  bleached  more  conveniently  by  using  caustic  pyrozone. 
The  remedy  can  be  applied  in  the  canal  loosely  on  cotton.  To  hasten 
the  liberation  of  oxygen,  a  heated  platinum  wire  can  be  gently  placed 
on  the  cotton.  The  wire  should  not  be  too  hot,  as  the  heat  may  cause 
a  flame  from  the  ether  in  the  solution.  Heated  dry  air  may  also  be 
used  for  the  same  purpose.  After  each  application  the  tooth  struc- 
ture should  be  thoroughly  washed  with  a  warm  alkaline  solution,  and 
the  process  repeated  until  the  color  is  satisfactorily  restored. 

If,  after  repeating  the  application  two  or  three  times,  the  tooth  is 
not  satisfactorily  bleached,  the  solution  may  be  hermetically  sealed 
in  the  cavity  (see  Fig.  93).  If  the  cavity  is  small  and  on  the  lingual 
surface,  the  sealing  can  best  be  done  by  the  use  of  gutta-percha  (not 
temporary  stopping) .  The  excess  of  solution  can  be  dried  from  the 
cavity  and  the  hot  gutta-percha  applied,  the  heat  of  which  hastens 
the  liberation  of  oxygen  which,  together  with  the  expansion  of  the 
confined  ether,  is  carried  into  the  entire  tubular  structure  of  the  den- 


DISCOLORED    TEETH 


409 


tin.  It  is  well  to  have  the  gutta-percha  just  flush  with  the  margins 
of  the  cavity  and  then  cover  it  with  cement.  By  this  means  we  are 
doubly  certain  that  the  remedy  cannot  escape.  The  final  treatment 
is  exactly  the  same  as  in  using  sodium  dioxid. 

Caustic  pyrozone  is  a  very  escharotic  agent,  and  equally  as  much 
care  should  be  taken  to  prevent  the  remedy  from  coming  in  contact 
with  the  soft  tissues  of  the  mouth  or  the  fingers  of  the  operator  as  in 
using  sodium  dioxid.  The  remedy  being  in  liquid  form  is  more 
easily  handled  than  the  sodium  dioxid  powder. 


Fig.  93. — This  is  the  case  of  a  young  lady,  about  17  years  of  age,  who  met  with  an 
accident  in  which  the  maxilla  was  fractured,  loosening  the  central  and  lateral  incisors. 
The  fracture  was  reduced  by  Dr.  W.  H.  G.  Logan.  About  one  year  later  the  central 
began  to  discolor  slightly,  when  patient  was  referred.  The  tooth  was  opened  on  Dec. 
29,  1914,  and  the  pulp  was  found  to  be  dying,  though  not  completely  dead.  For- 
mocresol  was  sealed  in  contact  with  the  tissue.  On  Jan.  4,  1915,  the  pulp  was  removed 
and  phenolsulphonic  acid  was  employed.  Phenol  compound  was  sealed  in  the  canal. 
The  root-filling  operation  was  performed  on  Jan.  7,  and  the  color  restored  by  sealing 
caustic  pyrozone  in  the  canal;  after  which  a  lingual  filling  was  inserted.  The  radio- 
graph was  taken  April  i,  1916,  about  fifteen  months  after  the  root-filling  operation.  The 
color  of  the  tooth  at  this  time  was  perfectly  normal.  Notice  that  there  is  no  periapical 
involvement. 


The  other  direct  oxidizing  agents  are  used  in  practically  the  same 
way.  The  alphozone  and  acetozone  powder  can  be~  placed  in  the 
cavity,  moistened  with  an  alkaline  solution  and  hermetically  seaead. 
The  volume  of  oxygen  liberated  from  these  agents  is  not  great,  and 
the  process  of  bleaching,  therefore,  is  much  slower  than  when  sodium 
dioxid  or  caustic  pyrozone  is  used. 

In  conclusion,  I  desire  to  say  that  in  the  bleaching  of  teeth  we  find 
a  practical  application  of  the  science  of  chemistry  to  the  practice  of 
dentistry,  and  that  in  the  discoloration  of  tooth-structure  from  the 
various  sources  can  be  found  a  fruitful  field  for  further  investigation 


AXTRUIM  OF  HIGHMORE 
GENERAL  CONSIDERATIONS 

The  antrum  of  Highmore,  or  maxillary  sinus,  is  a  chamber  or 
cavity  in  the  body  of  the  superior  maxillary  bone  on  either  side  of  the 
jaw.  It  should  be  remembered  in  connection  with  the  therapeutics 
of  the  diseases  of  the  antrum  that  the  cavity  is  normally  lined  with 
mucous  membrane,  which  is  continuous  from  the  nasal  cavity  through 
a  small  opening,  called  the  ostium  maxillare;  that  the  cavity  varies 
in  location  and  size,  and  is  capable  of  containing  from  two  drams 
(8.0  mils)  to,  sometimes,  one  ounce  (30.0  mils)  of  fluid.  Fortunately, 
the  dentist,  in  general  practice,  is  not  often  called  upon  to  treat  dis- 
eases of  the  maxillary  sinus,  but  when  a  case  presents  of  purely 
dental  origin,  he  should  be  prepared  to  make  a  correct  diagnosis  and 
to  properly  treat  the  case.     (See  Figs.  94  and  95.) 

Causes  of  Diseases  of  the  Antrum. — There  are  many  contributing 
causes  of  diseases  of  the  maxillary  antrum,  among  the  more  import- 
ant of  which  are: 

I.  Dental  Conditions. — It  is  quite  generally  conceded  by  both 
rhinologists  and  dentists  that  the  teeth,  or  conditions  associated  with 
the  teeth,  are  the  greatest  source  from  which  the  membrane  lining  the 
chamber  may  become  irritated  to  the  extent  of  bringing  about  a  de- 
generation of  the  cells,  when  infection  is  liable  to  occur  and  pus  result. 
It  has  been  previously  mentioned  that  one  of  the  serious  com- 
plications of  alveolar  abscesses  is  where  the  pus  is  evacuated  into 
the  antral  cavity,  instead  of  working  its  way  through  the  labial  or 
buccal,  and  sometimes  through  the  lingual  plate  of  bone  emptying 
into  the  mouth,  as  is  the  case  usually.  (See  Fig.  55.)  The 
author  reports  here  two  cases  in  the  College  Infirmary  where  a  stu- 
dent had  removed  a  vital  pulp  and  entered  the  antrum  through  the 
canal,  showing  that  all  that  separated  the  end  of  the  root  from  the 
floor  of  the  antrum  was  the  mucoperiosteum,  which  the  student 
penetrated.  One  case  was  the  lingual  canal  of  a  first  molar,  and  the 
other  the  canal  of  a  second  bicuspid.  Other  cases  of  this  character 
have  since  been  observed  in  the  College  clinic.  If  abscesses  occur  in 
connection  with  teeth  thus  situated  in  the  jaw,  the  antrum  will  at 
once  become  involved. 

410 


ANTRUM    OF    HIGHMORE 


411 


Hiatus  semilunaris 


Ostium  maxillare 


;.v  ~^y^^^ 


Fig.  94. — Antero-posterior  division  through  the  maxillary  sinus.     (Cryer.) 


Sound  passing   through  in- 
fra-orbital canal  and  foramen 


Infra-orbital  sinus 


Infra-orbital  foramen 


Maxillary  sinus  (antrum) 


Opening  caused  by  apical 
abscess 


Fig.  95.— Vertical  transverse  section  showing  the  close  relation  of  the  roots  of  the  molar 
teeth  to  the  maxillary  sinus  (antrum).     (Cryer,  Dental  Cosmos.) 


412 


PRACTICAL   DENTAL   THERAPEUTICS 


2.  Catarrhal  Inflammation. — Since  the  Schneiderian  membrane 
which  lines  the  nasal  cavity  passes  through  the  ostium  maxillare  and 
the  continuation  of  it  lines  the  antral  cavity,  any  inflammation  of 
the  nasal  mucous  membrane,  if  continuous  and  progressive,  may 
involve  the  antrum.  Especially  is  this  true  of  patients  who  have 
catarrh,  influenza,  or  grip.  Even  an  acute  coryza  may  seriously 
involve  the  antrum. 

3.  Foreign  Material. — Foreign  material  constitutes  another  pro- 
lific source  of  disease  of  the  antrum.  Teeth,  especially  third  molars, 
have  been  known  to  erupt  into  the  antrum;  dentigerous  cysts  and 
polypi  are  frequently  found;  and,  occasionally,  in  the  careless  ex- 
traction of  a  pointed  root,  and  even  at  times  when  due  care  and  judg- 
ment are  exercised,  if  the  root  is  badly  decayed,  it  may  be  forced  by 
the  forceps  into  the  antral  cavity. 


Fig.  96. — This  radiograph  shows  a  case  of  suspected  antral  involvement.  There 
was  no  external  discharge  of  pus,  but  severe  neuralgia  and  some  of  the  other  subjective 
symptoms  of  antral  disease.  The  cuspid  and  first  bicuspid,  on  the  affected  side, 
carried  artificial  crowns.  The  radiograph  indicates  that  the  antrum  is  not  involved, 
but  shows  that  the  canal  of  the  cuspid  root  is  not  filled,  this  was  found  to  be  gangren- 
ous, also  a  necrotic  area  about  the  apical  end  of  the  imperfectly  filled  first  bicuspid 
root. 


4.  Traumatism. — The  antrum  frequently  becomes  involved  as  a 
result  of  some  traumatic  injury,  such  as  a  blow,  etc. 

It  is  frequently  difficult  to  make  a  correct  and  positive  diagnosis 
of  antral  disease.  The  symptoms  generally  are  of  the  subjective 
variety,  unless  the  cause  is  some  traumatic  injury,  in  which  case  the 
diagnosis  is  readily  made. 

Diagnosis. — The  symptoms  which  aid  in  arriving  at  a  diagnosis 
are :  A  sense  of  fullness  on  the  affected  side ;  at  times  the  pressure  may 
be  so  great  as  to  cause  the  eye  to  distend  from  its  orbit;  frequently  an 
odor  and  discharge  of  bloody  pus  or  mucus  through  the  nose,  especi- 
ally when  the  patient  coughs  or  sneezes,  or  when  he  lies  in  a  certain 
position.     The  use  of  the  X-ray  and  the  little  electric  mouth-lamp. 


ANTRUM   OF    HIGHMORE  413 

while  by  no  means  positive,  are  invaluable  aids  in  making  the  diag- 
nosis (see  Fig.  96).  By  pulling  down  the  shades,  making  the  room 
as  dark  as  possible,  and  placing  the  electric  mouth-lamp  on  the 
lingual  side  of  the  teeth  a  dead  pulp  may  be  detected  which  is  causing 
the  trouble.  Placing  the  lamp  higher  in  the  vault,  the  antrum,  if 
diseased,  will  .generally  present  a  more  cloudy  or  foggy  appearance 
than  will  the  healthy  antrum.  After  making  the  diagnosis,  the  next 
important  step  is  to  decide  on  the  method  of  treatment.  If  no 
dental  condition  seems  to  be  causing  the  disease,  the  patient  should 
be  referred  to  a  rhinologist  for  further  examination;  but  if  the  dis- 
eased condition  of  the  antrum  is  of  dental  origin,  it  is  the  prerogative 
of  the  dentist  to  treat  the  case,  if  he  so  desires. 

THERAPEUTICS 

The  treatment  is  of  two  kinds — surgical  and  medicinal. 

1.  Surgical  Treatment. — The  surgical  treatment  of  diseases  of  the 
antrum  will  be  discussed  here  but  briefly.  To  intelligently  treat  the 
condition  it  is,  of  course,  essential  to  find  the  cause  and  remove  it. 
Let  it  be  understood  that  this  does  not  necessarily  mean  that  if  the 
cause  of  the  antral  trouble  is  an  abscessed  tooth,  it  is  necessary  to 
extract  the  tooth.  Frequently,  by  treating  the  affected  tooth  and 
opening  into  the  antrum  and  washing  out  the  cavity,  the  case  will 
yield  nicely.  Whether  it  is  necessary  to  extract  the  offending  tooth 
is  often  a  difficult  problem  to  solve.  Many  teeth  have  been  need- 
lessly sacrificed  in  the  surgical  treatment  of  diseases  of  the  maxillary 
antrum,  especially  by  the  general  surgeon;  while,  on  the  other  hand, 
many  antrums  have  become  chronically  diseased,  which  condition 
might  have  been  avoided  and  the  case  cured  during  its  incipiency, 
had  it  not  been  for  the  presumable  conservativeness  of  dentists,  espe- 
cially, in  their  efforts  to  cure  the  antral  disease  and  at  the  same  time 
save  the  tooth.  It  should  be  remembered  that  important  as  every 
tooth  is — a  healthy  antrum  is  of  greater  importance.  In  making  this 
statement  the  author  does  not  mean  to  encourage  the  needless  ex- 
traction of  teeth  in  connection  with  the  surgical  treatment. 

The  site  of  making  the  opening  depends  upon  the  conditions  as 
found.  Probably  no  two  cases  will  need  exactly  the  same  kind  of 
opening.  It  may  be  made  through  a  tooth-socket,  just  posterior  to 
the  canine  fossa,  between  the  roots  of  teeth,  or  through  the  nose. 
The  latter  opening  should  be  made  by  a  rhinologist,  if  necessary. 
The  tendency  at  first  is  to  make  the  opening  too  small  rather  than 
large  enough.     In  many  cases  it  is  necessary  to  have  the  opening 


414  PRACTICAL    DENTAL    THERAPEUTICS 

sufficiently  large  to  permit  an  ocular  or  digital  examination.  A 
thorough  examination  at  this  stage  of  the  operation  will  determine 
whether  the  cavity  needs  curettement  or  simply  the  establishment  of 
drainage  and  evacuation  of  the  pus  or  mucoserous  fluid. 

It  is  seldom  necessary  to  administer  a  general  anesthetic  other 
than  nitrous  oxid  and  oxygen  for  the  purpose  of  opening  into  the 
antrum  painlessly.  It  may  be  accomplished  in  most  cases  practically 
without  pain  by  the  use  of  local  anesthetics.  With  the  soft  tissues 
anesthetized  little  pain  is  produced  in  drilling  through  the  bone. 
Where  curettement  is  indicated,  a  general  anesthetic  had  better  be 
given.  Nitrous  oxid  and  oxygen  serves  the  purpose  admirably.  We 
now  come  to  the  phase  of  the  subject  of  most  interest  from  our  point 
of  view — the  therapeutics.  Before  discussing  the  drugs  used  in 
treating  diseases  of  the  antrum  of  Highmore,  I  desire  to  emphasize 
the  fact  that  it  matters  little  what  drugs  are  used  as  long  as  they  are 
practically  nonirritating  and  antiseptic,  if  the  surgical  treatment  has 
been  all  that  is  required.  If  the  cause  has  not  been  surgically  re- 
moved or  corrected,  drugs  will  be  of  little  avail;  for  this  reason  the 
surgical  treatment  has  been  discussed  here  briefly. 

2.  Medicinal  Treatment. — The  therapeutics  of  the  condition 
under  consideration  consists  in  washing  the  antral  cavity  with  bland 
remedies  for  the  purpose  of  disposing  of  the  pus  and  mucoserous 
fluid;  this  to  be  followed  by  antiseptic  and  stimulating  remedies. 
Any  bland  solution  may  be  used  which  is  nonirritating  and  antiseptic, 
provided  the  odor  and  taste  of  the  agent  employed  are  not  objection- 
able. A  warm  saturated  solution  of  boric  acid  serves  the  purpose 
admirably.  The  author,  however,  prefers  using  a  warm  sterile 
physiologic  salt  solution.  These  solutions  may  be  used  in  a  fountain 
syringe,  the  latter  being  placed  on  the  wall  as  high  as  convenient 
so  that  considerable  force  may  be  exerted  in  the  washing  process. 
A  glass  or  hard  rubber  point  should  be  attached  to  the  rubber  tubing, 
and  should  be  of  such  shape  and  size  as  to  pass  easily  into  the  open- 
ing. The  escape  of  fluid  from  the  syringe  should  be  controlled  by  a 
stop-cock.  By  this  means  the  cavity  can  be  well  flushed  out,  using 
a  considerable  quantity  of  fluid.  In  the  absence  of  a  fountain  syringe, 
a  strong  water  syringe  may  be  used.  The  physiologic  saHne  solution 
also  acts  as  a  stimulant  to  the  mucous  membrane.  After  thoroughly 
washing  the  cavity,  most  of  the  solution  which  naturally  remains  can 
be  absorbed  with  cotton  and  the  cavity  injected  full  of  some  antiseptic 
and  stimulating  remedy.  Brophy  recommends  argyrol,  using  all  the 
way  from  a  lo  to  a  50  per  cent,  solution. 

Beck  suggests  using  bismuth  paste.     This  has  the  distinct  ad- 


ANTRUM   OF   HIGHMORE  41S 

vantage  of  completely  filling  the  space  with  a  semi-solid,  oleaginous 
paste,  which  guards  against  septic  invasion  from  the  mouth,  and  at 
the  same  time  holds  the  stimulating  drug  in  contact  with  the  entire 
membrane  of  the  cavity.  Some  care  must  be  exercised  in  making  the 
injection  so  as  not  to  force  the  paste  into  communicating  sinuses.  The 
injection  may  be  repeated  as  often  as  the  necessity  of  the  case  de- 
mands. If  there  be  no  complication,  two  or  three  injections,  at  inter- 
vals of  two  or  three  days,  will  generally  suffice.  The  author  prefers 
using  antiseptic  and  stimulating  solutions,  like  25  per  cent,  argyrol, 
or  I  or  2  per  cent,  iodin,  rather  than  bismuth  paste. 

There  is  little  necessity  for  using  strong  disinfectant  or  cauteriz- 
ing agents  in  the  medicinal  treatment  of  diseases  of  the  maxillary 
sinus.  If  the  case  does  not  yield  to  the  treatment  here  given, 
some  complication  may  be  suspected,  for  which  see  works  on  Oral 
Surgery. 


PYORRHEA  ALVEOLARIS 
GENERAL  CONSmERATIONS 

Because  of  the  customary  use  of  the  term,  and  for  want  of  a 
better  one,  this  much-named  disease  has  been  called  throughout  this 
work  pyorrhea  aheolaris.  Generally  speaking,  it  may  be  con- 
sidered a  chronic  suppurative  disease  of  the  supporting  or  investing 
tissues  of  the  teeth  (gums,  pericemental  membrane  and  alveolar 
process),  progressing  insidiously  with  occasional  acute  exacerba- 
tions. The  disease  begins  as  an  interstitial  gingivitis;  the  gum 
septum  first  becomes  reddened,  then  swollen  and  tender  and  bleeds 
easily.  The  swollen  gum  frequently  assumes  a  deep  red  or  purple 
color  and  forms  spongy  festoons  between  the  affected  teeth  (see 
Fig.  98,  p.  4). 

The  true  pathology  and  etiology  of  this  disease  is  yet  an  unsolved 
problem,  notwithstanding  the  fact  that  its  solution,  for  years,  has 
been  attempted  by  the  most  scientific  men  of  the  profession.  In 
recent  years,  the  disease  has  engaged  the  attention  of  the  medical 
as  well  as  the  dental  profession;  for  it  is  now  well  recognized  that, 
whether  or  not  the  disease  is  of  purely  local  origin  or  is  a  local  mani- 
festation of  some  constitutional  disorder,  its  presence  in  the  mouth 
is  the  forerunner  of  many  grave  systemic  diseases. 

Probable  Causes. — The  causes  of  pyorrhea  alveolaris  may  be 
grouped  into  two  classes:  predisposing  and  active. 

The  conditions  which  predispose  to  the  disease  are  many  and 
varied,  and  include  the  following:  Faulty  occlusion,  irregular 
teeth,  faulty  or  no  contacts  between  teeth,  ill-fitting  crowns,  bridges 
and  partial  dentures,  calcific  deposits,  bacterial  plaques,  certain 
drug  poisons  (mercury),  certain  constitutional  diseases,  etc. 

The  active  or  exciting  cause  of  the  disease  is  a  pathogenic  micro- 
organism of  some  kind.  In  the  past  many  organisms  have  been 
credited  with  being  the  specific  cause  of  pyorrhea  alveolaris.  A 
bacteriologic  examination  of  the  pus  from  a  pyorrheal  pocket  will 
disclose  a  vast  number  of  bacteria.  The  difficulty  is  to  ascertain, 
with  any  degree  of  certainty,  which  organism  is  pathogenic  in  a 
case.     The  work  of  Barrett  and  Smith, ^  of  Philadelphia,  corroborated 

^Dental  Cosmos,  1914. 

416 


PYORRHEA  ALVEOLARIS  417 

by  that  of  Bass  and  Johns,  ^  of  New  Orleans,  would  seem  to  prove 
quite  conclusively  that  the  causative  agent  is  not  a  bacterial  organ- 
ism, but  a  protozoon — the  Endameba  huccalis,  and  perhaps  other 
species  of  endamebae. 

After  making  hundreds  of  smears,  Hartzell,^  of  Minneapolis, 
found  the  streptococcus  viridans  and  the  fusiform  bacillus  and  its 
accompanying  spirocheta  universally  present  in  all  pyorrheal  pockets 
and  on  tooth  surfaces.  This  author  concludes  by  saying,  "The 
finding  by  culture  of  viridans  below  the  level  of  attachment  in  the 
membrane  also  impresses  us  with  the  thought  that  streptococci 
are  the  principal  organisms  of  pyorrhea  alveolaris  and  that  amebae 
and  all  other  germs  are  contributing  factors  only."  Brook,^  of 
London,  England,  and  others,  have  also  found  the  streptococcus 
family  to  be  the  predominating  organism  in  infections  about  the 
teeth. 

Whether  the  endamebae  or  the  streptococci  viridans  or  other 
bacteria  are  the  specific  cause  will  not  be  discussed  further  here. 
Enough  has  been  introduced  to  show  that  the  true  pathology  and 
etiology  of  pyorrhea  alveolaris  are  still  unsolved  problems.  The 
efifects  of  the  disease  upon  the  system  will  now  engage  our  attention. 

Systemic  Effects. — The  systemic  effects  of  pyorrhea  alveolaris 
may  result  in  two  ways,  as  pointed  out  by  Brook:  (i)  By  the 
absorption  of  toxins  and  germs  locally,  through  the  infected  gums 
and  alveolar  process,  or,  (2)  by  the  absorption  of  toxins  after  the 
bacteria  have  entered  the  gastrointestinal  tract,  either  from  the 
stomach  or  intestines.  This  author  points  out  the  fallacy  of  the 
too  common  beUef  that  the  gastric  secretion  is  sufficiently  antiseptic 
to  kill  all  of  the  bacteria  reaching  the  stomach  from  the  mouth;  for 
he  states  that  the  same  type  of  streptococcus  found  in  the  pyorrheal 
pus  can  be  also  isolated  in  many  cases  from  the  feces  in  persons 
suffering  from  the  disease.  It  is  also  mentioned  that  a  very  limited 
amount  of  infection  in  the  mouth  may  give  rise  to  a  great  deal  of 
systemic  toxemia,  owing  to  the  fact  that  the  bacteria  multiply  at 
such  a  great  rate,  one  producing  many  millions  in  twenty-four  hours, 
so  that  even  a  trivial  amount  of  o^al  infection  may  mean  an  enormous 
number  of  pathogenic  bacteria  by  the  time  the  intestinal  contents 
are  evacuated  from  the  bowel. 

While  it  is  possible,  as  stated,  that  absorption  of  toxins  and  germs 
may  iake   place   locally  through  the  infected  gums  and  alveolar 

*  Journal  American  Medical  Association,  Feb.  13,  1915. 
^Dental  Review,  Sept.,  191 5. 
^Dental  Review,  June,  191 5. 
27 


41 8  PRACTICAL   DENTAL    THEEAPEUTICS 

process,  there  can  be  little  doubt  that  the  absorption  of  toxins  from 
the  gastrointestinal  tract  is  of  far  greater  significance.  Logan^ 
has  repeatedly  shovvTi  that  the  blood  count  in  cases  of  pyorrhea 
alveolaris  gives  very  little  e\ddence  of  infection  unless  the  pocket 
is  deep,  extending  to  or  nearly  to  the  root  apex  and  involving  the 
alveolar  process.  CarmichaeP  expresses  the  opinion  that  for  the 
bacteria  and  toxins  to  be  absorbed  locally,  it  is  essential  that  the 
pressure  within  the  infected  area  shall  exceed  the  pressure  within 
the  blood-vessels  themselves;  and  this  author  concludes  that  inas- 
much as  the  pyorrheal  pocket  in  the  vast  majority  of  cases  is  in 
open  and  direct  communication  with  the  oral  cavity  by  means  of 
an  external  sinus,  the  toxic  bacterial  products  Hberated  in  the  pocket 
are  far  more  frequently  emptied  into  the  mouth,  finding  their  way 
into  the  gastro-intestinal  tract,  rather  than  gaining  direct  entrance 
into  the  circulation.  This  theory  would  seem  to  prove  the  correct- 
ness of  Logan's  observations;  though  the  latter  author  does  not 
base  his  findings  on  such  a  theory,  nor  does  it  harmonize  with  the 
statement  of  bacteriologists  to  the  effect  that  certain  poisons  known 
as  extracellular  toxins  are  excreted  by  the  bacteria  directly  into  the 
tissues  or  blood-stream.  The  toxins  excreted  by  the  streptococcus 
viridans  are  extracellular.     (See  Biologic  Products,  p.  245.) 

With  this  knowledge  before  us,  it  will  be  interesting  to  trace  the 
pus,  containing  the  bacteria  and  toxins,  in  its  course  after  it  leaves 
the  pyorrheal  pocket,  and  to  learn  the  diseases  which  may,  and 
frequently  do,  result  therefrom.  This  has  been  well  done  by  Brook, 
from  which  author  I  here  quote :  ''The  pus  passes  first  into  the  mouth, 
where  it  may  give  rise  to  ulcerative  stomatitis,  mixing  here  with  the 
saliva,  it  flows  first  over  the  tonsils,  which  it  may  infect  mth  the 
result  of  acute  tonsillitis  and  quinsy.  It  then  passes  into  the  pharynx 
and  then  the  esophagus,  where  it  may  cause  pharyngitis  and  esoph- 
agitis.  Should  any  be  drawn  into  the  trachea  and  bronchi  it  may 
produce  bronchitis,  acute  and  chronic,  and  gravest  of  them  all — 
pneumonia  or  bronchopneumonia;  passing  down  the  esophagus  it 
next  enters  the  stomach.  Chronic  indigestion  is  by  far  the  common- 
est sequela  here,  but  another  very  grave  trouble  may  result — gastric 
ulcer. ^  In  the  small  intestine,  it  causes  chronic  intestinal  indiges- 
tion, and  flatulence,  and  may  infect  the  bile  duct,  giving  jaundice 
and  gall-stones,  etc.     It  then  enters  the  cecum  and  the  appendix. 

1  Various  Journal  articles. 

2  Dental  Review,  August,  1915. 

2  This  complication  has  been  pointed  out  by  Sir  Bertrand  Dawson,  of  England, 
and  conclusively  proven  by  Rosenow,  of  Chicago. 


PYORRHEA   ALVEOLARIS  419 

Passing  on  into  the  colon,  we  come  to  the  subject  of  colitis.  This 
disease  is  much  more  prevalent  than  is  commonly  thought.  It  is 
marked  by  diarrhea,  more  or  less  spasmodic,  and  the  passage  of  mucus 
in  the  stools.  In  acute  cases,  blood  in  more  or  less  large  quantities 
may  be  passed.  In  the  chronic  cases,  chronic  abdominal  pain  often 
amounting  to  colic,  diarrhea,  vmformed  stools,  or  occasional  con- 
stipation, local  abdominal  tenderness,  flatulence,  and  distention 
result."  In  connection  with  appendicitis,  this  author  emphatically 
states  his  view  that  a  large  majority  of  cases  are  due  to  pyorrhea 
alveolaris  and  nothing  else.  Most  of  the  cases,  if  examined,  show 
symptoms  of  the  disease,  often  of  old  standing,  and  then  the  same 
bacterium,  streptococcus  pyogenes  longus,  can  be  isolated  from  the 
pyorrheal  pocket  and  from  the  appendicular  abscess.  This  means, 
according  to  Brook,  that  had  the  patient  been  cured  of  this  pyorrhea 
before  his  appendix  became  infected  he  would  never  have  had  the 
attack  of  appendicitis  which  brought  him  into  the  hands  of  the 
physician  and,  perhaps,  surgeon. 

So  far  as  the  treatment  of  pyorrhea  alveolaris  is  concerned,  the 
author  is  of  the  opinion  that  a  mistake  has  been  made  by  the  profes- 
sion generally  in  grouping  all  of  the  disorders  commonly  called 
pyorrhea  alveolaris  under  one  heading  and  endeavoring  to  effect  a 
cure  of  the  entire  group  by  a  common  treatment.  It  is  true  that 
the  treatment  of  the  various  diseases  affecting  the  gum,  pericemen- 
tal, and  alveolar  tissues  have  many  things  in  common,  yet  the  correct 
treatment  must  necessarily  involve  special  measures  to  meet  the 
demands  of  a  given  case.  Therefore,  for  convenience  in  outlining 
our  treatment  the  various  disorders  so  commonly  grouped  under  the 
heading  of  pyorrhea  alveolaris  will  be  arbitrarily  divided  into  three 
classes.  It  must  be  understood,  however,  that  in  reahty  no  dis- 
tinct line  of  demarcation  can  be  drawn.  The  division  is  made 
purely  for  convenience  in  studying  the  disease  from  the  therapeutic 
point  of  view. 

DESCRIPTION  OF  CLASSES 

Class  I. — This  class  includes  such  cases  as  often  present  where 
upon  examination  it  will  be  noticed  that  around  several  teeth  in  the 
mouth,  just  under  the  free  margin  of  the  gum,  there  is  a  hard,  dark, 
flint-like,  annular  deposit,  which  in  some  instances  nearly  and  often- 
times completely  encircles  the  tooth.  This  deposit  comes  from  the 
blood,  and  is  known  as  serumal  calculus.  It  is  caused  by  some  local 
irritant  at  the  gum  margin,  generally  oral  fllth  and  bacteria,  which 
results  in  gingivitis — always  a  characteristic  symptom  of  this  class. 


420  PRACTICAL   DENTAL   THERAPEUTICS 

There  may  or  may  not  be  pus,  generally  there  is  not;  the  pockets,  if 
any,  are  shallow.  It  will  usually  be  noticed  that  there  is  more  or  less 
salivary  deposit  on  the  lingual  surfaces  of  the  lower  anterior  teeth 
and  on  the  buccal  surfaces  of  the  upper  first  and  second  molars. 
The  general  condition  of  the  mouth  gives  every  evidence  of  neglect, 
which  may  be  considered  the  cause  of  this  class  of  pyorrhea  alveolaris. 
Fig.  97  shows  the  extent  to  which  saUvary  deposits  may  accumulate 
in  a  neglected  mouth.  Fig.  99  shows  the  results  which  frequently 
follow  faulty  occlusion. 


Fig.  97. — This  shows  the  extent  to  which  salivan'  calculus  will  form  on  the  roots  of 
the  lower  anterior  teeth  in  some  mouths,  if  neglected.  The  crown  is  nearly  covered 
as  is  also  most  of  the  root — only  a  small  portion  near  the  apex  being  free  from  deposit. 

Class  n. — This  class  is  what  might  properly  be  called  true  pyor- 
rhea alveolaris.  In  it  will  be  considered  those  aggravated  cases 
wherein  there  is  Httle  e\T[dence  of  gingivitis;  the  gum,  in  fact,  appears 
anemic  rather  than  h\"peremic,  and  is  gradually  receding  from  the 
neck  of  the  tooth.  The  pericemental  membrane  is  being  rapidly 
destroyed;  the  alveolar  process  is  resorbed — \drtually  melting  away; 
the  pockets  are  deep  and  variously  located  around  the  single  root  of 
a  tooth,  and  oftentimes  between  the  roots  of  multi-rooted  teeth. 
Pus  is  generally  present,  and  there  may  or  may  not  be  hard  deposits. 
Unless  the  disease  is  checked,  there  is  a  progressive  loosening  of  the 
teeth,  to  the  extent  that  they  ultimately  drop  out.  The  cause  of 
this  class  is  unknown.  It  may  be  a  bacterium,  but  as  yet  no  specific 
germ  has  been  satisfactorily  demonstrated  to  be  the  exciting  agent, 
though  the  presence  of  various  pathogenic  germs  has  been  scientifi- 
cally proven,  as  is  evidenced  also  clinically  by  the  pus  formation. 
Surely  the  cause  cannot  be  neglect  on  the  part  of  the  patient,  for 
the  disease  occurs  and  often  persists  in  the  mouths  of  patients  who 
are  scrupulously  clean  so  far  as  the  toilet  of  the  niouth  is  concerned. 
The  cause  in  far  too  many  instances  can  rather  be  traced  to  neglect 
on  the  part  of  the  family  dentist,  who  either  failed  to  recognize  and 
cure  the  disease  in  its  incipiency,  or,  recognizing  it,  informed  the 


Fig.  98. — The  picture  of  the  model  on  the  left  shows  a  typical  case  of  Class  I, 
involving  both  central  and  one  lateral  incisors.  The  picture  of  the  model  on  the  right 
shows  a  pyorrheal  case  which  has  been  treated  and  cured.  The  central  was  treated 
by  the  author  in  1904,  the  cuspid  in  1915.  The  case  being  a  referred  one,  I  did  not 
see  the  patient  from  the  time  the  pocket  along  the  labial  of  the  central  was  cured  until 
the  cuspid  became  involved.  The  results  here  emphasize  the  advisability  of  surgically 
eliminating  the  pocket  whenever  indicated. 


Fig.  99. — This  picture  is  from  a  model  taken  of  a  case  where  the  upper  third  molar 
prevented  the  lower  third  molar  from  fully  erupting.  Food  pocket  between  the  upper 
second  and  third  molars,  causing  the  third  to  decay.  Frequently  pyorrheal  pockets 
form  from  just  such  conditions.  Where  the  third  molars  are  the  teeth  involved,  it  is 
generally  best  to  extract  the  tooth,  as  was  done  in  this  case.  The  upper  third  molar 
shown  in  the  picture  is  the  actual  tooth  extracted.  It  was  placed  in  the  impression, 
and  the  model  made. 


PYORRHEA   ALVEOLARIS  42 1 

patient  that  nothing  at  all  could  be  done  and  advised  letting  it  go, 
ultimately  extracting  the  teeth.  It  is  sadly  to  be  regretted  that  so 
many  teeth  have  been  needlessly  lost  in  the  past  because  of  the  seem- 
ing indifference  of  dentists;  but  the  wave  of  prophylaxis  that  is 
floating  over  the  profession  to-day,  due  to  the  efforts  of  D.  D.  Smith 
and  others,  is  an  encouraging  sign  that  individual  dentists  are  either 
equipping  themselves  to  combat  the  disease  or  are  referring  the 
patients  thus  afflicted  to  dentists  who  are  so  equipped.  Fig.  loo 
illustrates  a  tj^ical  case  of  this  class. 


Fig.  100. — This  shows  the  recession  of  gum  tissue  due' to  the  resorption  of  the  alveolar 
process  between  the  central  incisors — the  result  of  pyorrhea  alveolaris. 

Class  m. — In  this  class  will  be  considered  those  cases  in  which 
we  are  reasonably  certain  that  the  local  condition  in  the  mouth  is 
at  least  aggravated  by,  if  not  entirely  due  to,  some  systemic  derange- 
ment. It  has  been  quite  clearly  demonstrated  by  Pierce,  Rhein, 
Talbot,  Kirk,  Fletcher  and  others,  that  at  least  certain  kinds  of 
pyorrhea  alveolaris  are  closely  associated  with,  if  not  caused  by,  such 
general  diseases  and  conditions  as  syphilis,  tuberculosis,  actinomy- 
cosis, diabetes,  osteomyelitis,  salivation,  phosphor  poisoning,  mal- 
nutrition, and  faulty  metabolism  in  general.  The  symptoms  here 
are  variable,  and  depend  largely  upon  the  general  complication. 
In  such  diseases  as  syphilis,  tuberculosis,  actinomycosis,  and  osteo- 
myelitis, the  alveolar  process  is  extensively  involved  and  usually 
rapidly  resorbed,  the  teeth  are  loosened,  there  is  generally  an  absence 
of  hard  deposits,  the  pus  is  persistent,  and  recovery  is  much  slower 
than  usual.  In  diabetes  the  gums  are  often  turgid  and  raw,  the 
pericemental  membrane  is  inflamed  and  highly  sensitive,  there  is 
a  tendency  toward  the  formation  of  serumal  deposits,  and  pus  may 
or  may  not  be  present.  The  mouth  symptoms  of  salivation  or 
mercurial  stomatitis  and  phosphor  poisoning  have  been  elsewhere 
described.  In  faulty  metaboHsm  the  symptoms  are  variable,  and 
none  has  been  demonstrated  to  be  truly  characteristic  of  the 
general  condition.  Pyorrhea  alveolaris  was  formerly  thought  by 
certain  investigators  to  be  caused  by  gout  or  what  was  known  as 
the  "rheumatic  diathesis."     To-day  it  has  been  definitely  proven 


422  PRACTICAL   DENTAL   THERAPEUTICS 

that  rheumatism  (arthritis)  is  due  to  an  infection,  and  the  foci  of 
infection  has  frequently  been  traced  to  pyorrheal  pockets  about  the 
teeth. 

With  this  understanding  of  the  conditions  which  present  in  the 
various  classes  of  the  disease  under  consideration,  we  will  now  discuss 
the  treatment. 

THERAPEUTICS 

When  cases  of  pyorrhea  alveolaris  present  for  treatment,  the 
first  important  consideration  is  to  impress  upon  the  minds  of  the 
patients  the  fact  that  you  must  have  their  hearty  cooperation, 
and  that  in  order  to  obtain  permanent  results  it  will  be  necessary 
for  them  to  follow  your  instructions  closely.  There  is,  perhaps,  no 
condition  which  dentists  are  called  upon  to  treat  wherein  the  con- 
fidence, and  especially  the  cooperation  of  the  patient  is  of  such  vital 
importance,  so  far  as  permanent  results  are  concerned,  as  in  the  treat- 
ment of  true  pyorrhea  alveolaris;  and  it  is  truly  surprising  what  good 
results  can  be  accomplished  by  the  conscientious  and  persistent 
efforts  of  both  dentist  and  patient. 

Before  undertaking  the  treatment  of  a  case,  then,  there  should 
be  a  distinct  understanding  as  to  what  may  reasonably  be  expected. 
The  discerning  patients  will,  naturally,  want  to  know  at  the  outset 
if  their  cases  can  be  cured.  The  word  "cure"  here  is  but  a  relative 
term,  and  an  explanation  should  be  made  in  regard  to  what  a  so- 
called  cure  includes.  It  does  not  mean  that  the  lost  tissues — gum, 
pericemental,  and  alveolar — can  be  restored.  It  should  mean,  how- 
ever, that  the  teeth  treated  can  ultimately  be  made  healthy,  com- 
fortable, and  useful,  so  far  as  mastication  is  concerned.  Any  tooth 
which  we  cannot  reasonably  expect  to  restore  to  this  condition  had 
better  be  considered  a  hopeless  tooth  and  extracted  at  once,  and 
there  are  many  such  in  the  mouths  of  pyorrheal  patients. 

As  has  been  elsewhere  explained,  while  the  presence  of  pus 
which  is  constantly  being  mixed  and  swallowed  with  the  saliva  and 
food  is  of  greater  importance,  so  far  as  health  is  concerned,  than  is 
the  looseness  of  the  teeth  in  the  jaw,  patients,  until  recently,  were 
more  interested  in  the  latter  phase  of  the  question;  and  they  are 
always  anxious  to  know  whether  the  now  loosened  teeth  will  become 
firmly  fixed  in  the  jaw  after  the  treatment.  This  all  depends  upon 
the  case  at  hand  and  the  mechanical  treatment  involved.  In  the  past 
too  much  dependence  has  been  placed  in  drugs,  and  too  much  also  has 
been  left  to  Nature  to  tighten  the  teeth,  when  this  should  not  have 
been  expected  on  account  of  the  extensive  loss  of  the  supporting 


Fig.  ioi. — This  picture  is  of  a  model  taken  of  a  case  after  being  cured  of  pyorrhea 
alveolaris.  Notice  the  second  bicuspid  which  was  badly  affected  and  loose,  but  is  now 
firm  and  comfortable. 


PYORRHEA   ALVEOLARIS  423 

or  investing  tissues ;  and  the  conscientious  dentist  who  makes  extrava- 
gant statements  in  this  respect  will  cause  much  disappointment 
to  both  himself  and  to  the  patient.  It  is  surprising,  at  times,  how 
loosened  pyorrheal  teeth  will  tighten  in  the  jaw  under  proper  treat- 
ment without  mechanical  assistance,  but  too  much  should  not  be 
promised  in  this  respect  (Fig.  loi).  The  author  desires  to  speak 
plainly  on  this  point,  for  herein  often  lies  the  greatest  source  of  dis- 
appointment. Unless  the  end  of  the  root  is  resorbed,  leaving  it 
roughened,  the  pus  formation  can  be  checked,  the  gum  can  be  made 
to  resume  a  healthy  appearance,  but  many  times  the  teeth,  without 
mechanical  aid,  will  not  materially  tighten,  though  otherwise  they 
are  perfectly  healthy  and  comfortable.  Their  usefulness,  of  course, 
is  impaired  on  account  of  their  being  loose. 

A  thorough  understanding  at  the  beginning  of  the  treatment, 
then,  serves  as  a  means  of  stimulating  confidence  on  the  part  of  the 
patient  in  the  operator's  ability  to  meet  the  conditions  as  found  and 
the  conscientiousness  with  which  he  works.  No  dentist  should 
undertake  the  treatment  of  a  case  of  true  pyorrhea  alveolaris  unless 
he  is  equipped  to  render  the  best  possible  service,  considering  always 
the  personal  equation,  and  then  only  with  the  understanding  that 
both  he  and  the  patient  are  to  work  in  harmony — each  exerting  their 
best  efforts  to  eradicate  the  disease.  It  is  far  better  not  to  undertake 
the  treatment  of  a  case  than  to  have  it  end  in  disappointment. 

The  detailed  treatment  of  the  three  classes  into  which  the  dis- 
orders commonly  called  pyorrhea  alveolaris  have  been  divided  will 
be  considered  separately,  for  herein  lies  the  value  of  making  the 
subdivisions.  The  treatment  is  of  three  kinds — surgical,  medicinal, 
and  mechanical. 

CLASS  I 

1.  Surgical  Treatment. — In  this  class,  it  will  be  remembered, 
deposits  are  always  in  evidence.  The  first  step  in  the  treatment  is 
to  remove  the  deposits.  This  is  accompHshed  by  instrumentation, 
care  being  taken  to  remove  the  irritant  material  without  undue 
injury  to  gum,  pericementum,  and  tooth-structures.  The  instru- 
ments which  the  author  uses  for  this  purpose  are  the  Logan-Buckley 
set,  illustrations  and  brief  descriptions  of  which  are  found  in  Fig. 
102.  Another  very  excellent  set  of  instruments  is  known  as  the  Carr 
set.  By  the  use  of  either  of  these  sets  of  instruments  the  deposits 
can  be  removed  with  a  minimum  amount  of  injury  to  the  structures 
involved.  Mawhinney  has  especially  emphasized  the  injury  done 
to  the  so-called  dental  ligament  and  the  other  soft  tissues  by  careless 


424 


PRACTICAL  DENTAL   THERAPEUTICS 


^ 


rj 


" "" ■"'■'■ """■"" ' ' """f ;: '■ -til 


Fig.  io 2.— Logan-Buckley  set  of  pyorrhea  and  prophylactic  instruments. 
t  or  description  of  their  uses,  see  next  page. 


PYORRHEA    ALVEOLARIS  425 

instrumentation,  and  Patterson,  James,  Hartzell,  and  others  have 
demonstrated  the  fact  that  better  results  are  obtained  when  the 
deposits  are  removed  in  such  a  manner  as  to  leave  the  tooth-surface 
smooth  and  easily  polished.  Extreme  care  should  always  be  taken 
in  removing  hard  deposits  from  the  necks  of  teeth  to  avoid  having 
the  deposit  when  loosened  fly  in  the  eye  of  the  operator  or  patient. 
Several  cases  are  on  record  where  the  dentist's  eye  became  seriously 
infected,  and  in  a  few  cases  the  sight  was  lost  by  such  an  accident. 

Before  beginning  the  scaling  process  the  mouth  should  be  thor- 
oughly sprayed  or  rinsed  with  an  antiseptic  solution.  For  this 
purpose  the  author  uses  cinnamon  water  to  which  about  2  per  cent, 
of  alcohol  is  added.  The  cinnamon  water  is  an  agreeable  solution, 
and  the  alcohol  aids  in  removing  the  mucoid  material  with  which  the 
teeth  in  this  class  of  cases  are  generally  coated.  A  glassful  of  the 
cinnamon  water  should  also  be  in  a  convenient  place.  This  solution 
.can  be  colored  pink  or  a  reddish  tinge  by  adding  a  small  amount  of 
tincture  of  cudbear.  The  object  in  having  the  solution  colored  is  to 
prevent  the  patient  from  seeing  the  blood  which  is  always  more  or 
less  in  evidence  in  scaling  these  teeth  on  account  of  the  gingivitis — 
a  characteristic  symptom  of  this  class.  The  solution  is  used  with  a 
strong  water  syringe  as  often  as  is  necessary  to  clear  the  field  of  opera- 
tion. The  scaling  should  be  begun  on  some  certain  tooth  in  the 
mouth  and  this  should  not  be  left  until  it  is  thoroughly  scaled.  This 
can  only  be  done  with  any  degree  of  certainty  by  following  some  defi- 

BRIEF  DESCRIPTION   OF  HOW  TO  USE  THE  LOGAN-BUCKLEY  SET  OF  INSTRUMENTS 

These  instruments  are  so  designed  that  the  teeth  may  be  scaled  systematically. 
Beginning  on  the  mesiobuccal  surface  of  an  upper  molar  or  bicuspid  tooth,  the  in- 
struments are  used  as  follows:  No.  i  for  the  mesiobuccal,  No.  2  for  the  buccal,  No.  3 
for  the  distobuccal,  No.  4  for  the  distolingual,  No.  5  for  the  lingual,  and  No.  6  for  the 
mesiolingual  surface.  These  six  instruments,  therefore,  scale  systematically  around 
the  tooth.  If  at  any  point  a  pocket  is  found  too  deep  to  be  reached  with  these  instru- 
ments, their  counterparts,  except  with  a  narrower  point  and  exaggerated  in  form,  are 
found  in  Nos.  16  to  21  inclusive.  For  example,  No.  16  is  the  exaggerated  form  of  No. 
I,  and  so  on  with  the  entire  six  instruments.  For  the  lower  teeth  the  positions  of  the 
instruments  are  exactly  reversed,  i.e.,  Nos.  i  and  16  are  here  used  on  the  mesiolingual 
surface,  etc.  With  one  or  the  other  of  these  groups  of  six  instruments  the  molar  and 
bicuspid  teeth  can  be  scaled,  except,  occasionally,  where  deep  pockets  are  found  between 
the  roots  of  molar  teeth  and  on  the  lingual  surface  of  the  divergent  lingual  root  of  upper 
molars.  For  these  exceptional  cases,  Nos.  9  and  10  are  right  and  left  and  are  employed 
for  scaling  between  the  roots  of  molars,  and  Nos.  24  and  25  are  right  and  left  for  the 
lingual  surface  of  a  divergent  lingual  root  of  upper  molars.  No.  23  is  for  the  distal 
surfaces  of  posterior  teeth  (third  molars). 

For  the  anterior  teeth,  upper  and  lower.  No.  7  is  designed  for  the  lingual  surfaces, 
and  No.  8  for  the  labial.  In  cases  where  there  is  a  deep  lingual  pocket  which  cannot  be 
reached  with  No.  7,  No.  22,  the  exaggerated  form,  can  be  used.  No.  11  is  a  push  instru- 
ment used  in  removing  deposit  from  between  crowded  and  irregular  teeth.  No.  15  is  a 
general  hook  for  removing  the  bulky  deposit  before  the  more  delicate  instruments  are 
used.  Nos.  12,  13,  and  14  are  prophylactic  instruments  which  can  be  used  with  either 
a  push  or  pull  movement  and  will  be  found  useful  in  removing  superficial  decay  and  in 
smoothing  and  polishing  rough  surfaces. 


426 


PRACTICAL   DENTAL   THEBAPEUTICS 


nite  system.  By  using  either  of  the  sets  of  instruments  mentioned, 
the  scaling  can  be  done  systematically.  With  the  L.-B.  set,  the 
author  begins  on  the  mesiobuccal  surface  of  the  upper  third  molar, 
and  with  the  six  instruments  designed  for  the  purpose  one  can  work 
completely  around  the  tooth  in  an  intelligent  manner.  From  here 
we  can  proceed  from  one  tooth  to  another  around  the  arch,  using  the 
instruments  designed  for  the  various  surfaces.  If  there  be  a  bulky 
deposit,  such,  for  instance,  as  salivary  deposits,  this  should  be  re- 
moved first  with  the  hook  instrument  designed  especially  for  this 
purpose. 


Fig.  103. — This  shows  the  instruments  in  their  proper  places  in  the  tray  ready  for  use. 


After  an  instrument  has  been  used  the  point,  at  least,  should  be 
kept  immersed  in  an  antiseptic  solution  during  the  entire  time  the 
scaling  is  being  done.  This  can  best  be  done  by  having  a  tray  which 
is  designed  to  hold  the  instruments  in  their  proper  places.  Such  a 
tray  with  the  entire  L.-B.  set  of  instruments  in  their  proper  places  is 
illustrated  in  Figs.  103  and  104. 

The  instruments  are  presumed  to  be  sterile  before  they  are  used; 
it  is,  therefore,  unnecessary  to  have  a  strong  disinfecting  solution  in  the 
tray.  Such  a  solution  would  either  act  upon  the  instruments  or 
taste  badly  when  the  instrument  is  placed  in  the  patient's  mouth,  for 
the  necessary  instrument  should  be  taken  directly  from  the  rack  of 
the  tray  and  used  in  the  mouth.  A  pleasant  antiseptic  solution, 
therefore,  should  be  in  the  tray.  It  is  a  principle  in  surgery  to  avoid 
the  presence  of  germs  by  having  the  instruments  sterile  before  using 
rather  than  to  endeavor  to  kill  the  germs  by  the  use  of  strong  disinfec- 
tants during  the  operation.     The  author  uses  a  20  per  cent,  solution 


PYORRHEA   ALVEOLARIS 


427 


of  phenol  compound  in  glycerin,  and  of  this  about  10  min.  (0.6  mil)  is 
added  to  about  }/2  pint  (240.0  mils)  of  sterile  water,  which  is  in  the 
tray.  This  solution  can  also  be  colored  with  tincture  of  cudbear 
to  conceal  the  blood. 

The  pockets  here,  if  any,  are  not  deep;  the  deposits  are  readily 
removed,  and  a  number  of  teeth  may  be  scaled  at  one  sitting.  Un- 
less there  be  some  good  reason  for  extending  the  length  of  time  of  the 
operation,  it  should  be  limited  to  one  hour,  and  the  scaling  process 
should  be  stopped  in  sufi&cient  time  to  permit  a  thorough  prophylactic 
treatment  with  Arkansas  and  carborundum  stones,  orange  wood, 


^^^W^pr^^ 

\           l^fl 

*  ^?:*i«^  •■  -  ^-*— -rV-"^  r 

1 

H    ^    ,    .          '''^'^  2*  25  26  27  28  29  30 

d 

^..'*'^H 

ti^.  .     ^ 

FxG.  104. — This  shows  how  the  inner  rack  can  be  removed  for  the  purpose  of  sterilization. 

pumice,  and  tape,  according  to  the  method  of  D.  D.  Smith,  before 
applying  the  medicinal  treatment.  The  teeth  here  are  not  loose  and, 
therefore,  they  need  no  mechanical  support.  A  record  should  be 
kept  of  the  teeth  treated  at  each  sitting,  so  that  we  may  know 
exactly  where  to  begin  when  the  patient  returns.  HartzelP  advises 
the  prophylactic  treatment  before  undertaking  the  root  surgery.  On 
this  point  he  says:  "Experience  has  taught  us  that  the  logical  place 
to  begin  the  treatment  of  pyorrhea  is  the  tooth's  surface  and  that 
the  first  step  in  the  treatment  of  any  pyorrhea  is  to  demonstrate  to 
the  patient  and  to  the  operator  the  relative  amount  of  bacterial 
growth  on  the  tooth's  surface.  This  is  important  to  both — impor- 
tant to  the  patient  because  it  directs  his  attention  to  those  areas  of 
the  tooth's  surface  which  need  the  greatest  daily  care,  and  important 
to  the  operator  because  it  explains  to  him  the  reason  for  gingival 


^  Dental  Review,  September,  1915. 


428  PRACTICAL   DENTAL   THERAPEUTICS 

inflammation  where  oftentimes  no  other  rational  cause  can  be  found. 
These  areas  may  be  shown  by  using  'disclosing solutions.'^  Follow- 
ing such  demonstration,  the  next  step  should  be.  the  elimination  of 
all  rough  areas  on  the  tooth's  surface  which  may  retain  bacteria  on 
or  in  the  tooth-surface,  and  this  is  accompHshed  by  applying  to  them 
Arkansas  and  carborundum  stones,  swinging  them  across  the 
enamel  surfaces,  thus  bringing  out  all  pits  that  have  been  induced 
by  the  acid  formed  by  the  bacteria  on  these  surfaces,  getting  rid  of 
the  bacteria  themselves  and  poHshing  out  the  inequalities,  which 
serve  to  retain  and  foster  bacterial  growth.  After  the  use  of  the 
coarse  stones  on  the  tooth-surfaces,  disclosing  solution  should  again 
be  used  to  make  sure  that  all  pits  have  been  beveled  out.  After 
all  pits  that  contain  bacteria  and  inequalities  have  been  thus  beveled 
out,  and  the  application  of  the  disclosing  solution  reveals  nothing, 
then  the  tooth-surface  should  be  thoroughly  poHshed  with  fine 
Arkansas  stones,  and  the  brilliance  increased  by  the  use  of  moose- 
hide  wheels  loaded  with  jeweler's  rouge  or  any  other  abrasive  which 
will  give  a  high  degree  of  brilliance  to  the  enamel.  When  the  tooth's 
surface  has  been  properly  cared  for  in  this  manner  we  are  then  ready 
to  attack  the  root-surface."  Whether  the  prophylactic  treatment 
is  given  the  crown  surface  of  the  tooth  before  or  after  the  root  sur- 
gery, it  should  be  done  thoroughly  before  applying  the  medicinal 
treatment. 

2.  Medicinal  Treatment. — After  the  teeth  have  been  thoroughly 
scaled  and  poUshed,  the  mouth  should  again  be  carefully  sprayed 
with  the  antiseptic  solution,  forcing  it  well  between  the  teeth  and 
around  the  gum  margins  to  mechanically  remove  any  loose  deposit 
and  pumice  which  may  be  left  from  the  polishing.  By  the  use  of 
cottonoid  rolls  the  parts  treated  can  be  kept  dry  and  an  application 
made  of  some  astringent  remedy.  This  can  be  worked  with  a  glass 
instrument  under  the  free  margin  of  the  gum  and  over  the  gum  sep- 
tum, keeping  the  parts  dry  for  a  few  moments,  when  the  mouth  can 
again  be  thoroughly  sprayed  and  rinsed  with  the  antiseptic  solution. 
If  the  teeth  are  at  all  responsive  to  heat  and  cold,  the  solutions  used 
should  always  be  warmed  to  the  temperature  of  the  body.  Spray- 
ing outfits  are  now  on  the  market  which  keep  the  solutions  warm; 
and,  if  the  dentist  devotes  much  time  to  pyorrheal  or  prophylactic 
treatment,  these  outfits  should  constitute  a  part  of  the  ofl&ce  equip- 
ment. As  a  local  astringent  in  these  cases,  the  author  suggests  the 
following : 

^  Strong  aqueous  solutions  of  iodin  and  potassium  iodid. 


PYORRHEA   ALVEOLARIS  429 

I^ — ^Zinci  phenolsulphonatis, 

Potassii  iodidi,  aa    gr.  xx  (1.3  Gm.) 
lodi  (crys.),  5ss  (2.0  Gm.) 

Mentholis,  gr.  iij  (0.19  Gm.) 

Thymolis,  gr,  ij  (0.13  Gm.) 

Glycerini,  q.  s.  ad.  f§j — M. 

Sig. — Use  as  directed  above. 

This  remedy  is  called  pyorrhea  astringent. 

The  patients  should  now  be  instructed  how  to  properly  brush, 
massage,  and  care  for  their  teeth  generally,  prescriptions  should  be 
written  for  a  tooth-powder  or  paste  and  an  antiseptic  mouth-wash, 
and  the  patient  dismissed  until  a  second  sitting.  In  giving  the 
instruction  relative  to  brushing  the  teeth  and  massaging  the  gums, 
it  should  be  emphasized  that  the  gums  should  be  vigorously  brushed 
as  well  as  the  teeth — thus  we  get  the  benefit  of  massage.  Many 
hand  and  electrical  appliances  are  also  on  the  market  for  massaging 
the  gums. 

The  above  treatment,  in  practically  every  detail,  should  be  re- 
peated at  each  sitting  until  the  mouth  is  in  good  condition,  after 
which  there  will  probably  be  little  need  for  further  medication.  The 
patient  should  be  requested  to  return  at  frequent  intervals  that  the 
case  may  be  watched,  and  each  time  the  patient  returns  an  examina- 
tion should  be  made  with  respect  to  the  care  given  the  teeth.  If  all  is 
well,  the  patients  should  be  complimented;  if  not,  they  should  be 
cautioned  accordingly. 

Astringent  Mouth-washes  Contraindicated. — The  general  pre- 
scribing of  mouth-washes  containing  highly  astringent  drugs,  as  the 
zinc  salts,  in  the  treatment  of  pyorrhea  alveolaris,  is,  in  the  opinion  of 
the  author,  wrong.  It  is  true  that  certain  tissues  of  the  mouth 
need  to  be  constringed  and  stimulated  to  healthy  activity,  but  surely 
the  entire  mucous  membrane  of  the  mouth  does  not  need  to  be  so 
treated.  Cook  has  shown  that  the  continuous  use  of  astringent 
mouth- washes  interferes  for  hours  with  the  action  of  the  ptyalin 
upon  starchy  foods.  The  astringent  remedy  should  be  applied  by 
the  dentist  to  the  parts  only  which  need  such  treatment,  and  an  anti- 
septic mouth-wash,  together  with  the  proper  brush,  tooth-powder  or 
paste,  and  other  utensils  for  the  mouth  toilet  is  all  the  patient  should 
use.  If  the  patient  is  to  use  an  astringent  remedy  at  all,  the  con- 
stringing  agents  should  rather  be  a  constituent  of  a  tooth-paste  than 
of  a  mouth- wash.    A  prescription  for  a  tooth-paste  follows : 


430  PIL^CTICAL   DENTAL   THEEAPEUTICS 

I^ — Calcii  carbonatis  ppt.,  oiijss  (112. o  Gm.) 

Saponis,  5ss  (16.0  Gm.) 

Sodii  benzoatis,  5j  (4-°  Gm.) 

Eucalj-ptolis, 

Olei  menthce  piperitae,  aa     m.  x  (0.6  mil) 
Th>Tnolis,  gr.  iv  (0.25  Gm.) 

Saccharini,  gr.  iij  (0.2  Gm.) 

Giycerim",  q.  s.  ad.  pasta. — M, 

Sig. — Use  as  a  tooth-paste. 

As  a  mouth- wash  any  known  antiseptic  solution  can  be  prescribed. 
It  is  as  unnecessary  as  it  is  un\s'ise  for  the  dentist  to  prescribe 
"cure-all"  mouth-washes  or  those  the  constituents  of  which  are  to 
him  unknown.  The  formerly  official  mouth-wash,  Liquor  Antisep- 
ticus,  (X.F.)  or  Dobell's  solution  (X.F.)  may  be  prescribed  and  diluted 
to  suit  the  case.     The  formula  for  the  Liquor  Antisepticus  follows: 

Boric  Acid,  5  dr.  (20.0  Gm.) 

Benzoic  Acid,  15  gr.  (i.o  Gm.) 

Thymol,  15  gr.  (i.o  Gm.) 
Eucal>-ptol,  4  min.  (0.25  mil) 

Oil  of  Gaultheria,  4  min.  (0.25  mil) 

Oil  of  Peppermint,  8  min.  (0.5  mil) 

Oil  of  Thyme,  2  min.  (o.i  mil) 

Alcohol,  8  fl.  oz.  (240.0  mils) 

"Water,  to  make  i  qt.  (1,000.0  mils) 

In  prescribing  this  solution  it  is  never  necessary  to  remember  all 
of  the  various  drugs  and  their  quantities.  We  can  take  advantage 
of  the  fact  that  the  solution  was  formerly  recognized  by  the  United 
States  Pharmacopeia  and  vvTite  its  official  title,  as: 

I^ — ^Liquoris  antiseptic!,  f§\^j  (240.0  mils) 

Sig. — DHute  with  one-half  of  warm  water  and  use  as  an  antiseptic 
mouth-vrash. 

It  is  well  to  remember,  however,  that  the  solution  contains  about 
2  per  cent,  of  boric  acid,  o.i  per  cent,  of  benzoic  acid  and  thymol, 
25  per  cent,  of  alcohol,  and  other  aromatics  and  antiseptics  added  to 
water  as  the  vehicle.  Herein  is  illustrated  a  practical  application  of 
a  knowledge  of  the  Pharmacopeia  and  National  Formulary. 

In  those  cases  compUcated  by  indigestion  and  where  the  patient 
complains  of  a  sour  taste  in  the  mouth,  especially  on  rising  in  the 
morning,  due  either  to  local  fermentation  or  to  the  regurgitation -lof 
acid  from  the  stomach,  the  condition  may  be  corrected  by  the  follow- 
ing prescription: 

I^ — Sodii  bicarbonatis,  5j  (4-o  Gm.) 

Infusi  gentianae  comp.,  fohj  (90.0  mils) — M. 

Sig. — Take  a  tablespoonful  before  meals  and  on  retiring. 


PYORRHEA   ALVEOLARIS  43 1 

Where  the  sour  taste  comes  purely  from  fermentation  in  the 
mouth,  all  that  is  necessary  is  to  have  the  patients  use  frequently  a 
warm  solution  of  sodium  bicarbonate,  or  the  following  alkahne  and 
antiseptic  mouth- wash  may  be  prescribed : 

I^ — Sodii  bicarbonatis, 

Sodii  boratis,  aa     3ss  (2.0  Gm.) 
Thymolis, 

Mentholis,  aa    gr.  ss  (0.03  Gm.) 

Alcoholis,  fSijss  (lo.o  mils) 

Glycerini,  fSij  (8.0  mils) 

Aquae  cinnamomi,  q.  s.  ad.  fSviij  (240.0  mils)  — M. 
Sig. — Use  wherever  an  alkaline  and  antiseptic  mouth-wash  is 
indicated. 

CLASS  II 

1.  Surgical  Treatment. — In  this  class  of  cases  we  are  dealing 
with  what  may  very  properly  be  called  true  pyorrhea  alveolaris, 
and  in  the  surgical  treatment  it  is  especially  necessary  to  use  such 
instruments  as  will  accomplish  our  end  in  a  definite  and  certain 
manner.  Here  the  exaggerated  forms  of  the  L.-B.  set  and  those 
designed  for  scaling  between  the  roots  of  molar  teeth  will  be  found 
extremely  useful.  If  deposits  are  present,  they  must  he  removed, 
observing  the  same  precautions  as  have  been  elsewhere  mentioned. 
In  the  absence  of  deposits,  the  pockets,  including  both  the  affected 
tooth-surface  and  alveolar  process,  must  be  thoroughly  curetted. 
We  have  here  a  more  aggravated  condition  with  which  to  deal,  and 
from  one  to  four  teeth  will  doubtless  be  all  that  should  be  treated  at 
one  time,  for  the  teeth  thus  operated  upon  are  usually  sore  and  more 
or  less  sensitive  to  thermal  changes;  therefore,  the  lesser  number  of 
teeth  treated,  the  greater  will  be  the  comfort  of  the  patient.  The 
pockets  are  generally  deep  in  this  class  of  cases,  and  compressed  air 
is  an  excellent  agent  to  use  for  clearing  the  field  and  locating  pockets. 
In  the  light  of  our  present  knowledge  of  focal  infection  and  the 
grave  systemic  diseases  resulting  therefrom,  it  must  ever  be  kept  in 
mind  that  all  teeth  which  cannot  he  treated  so  as  to  be  kept  free  from 
infection  should  be  extracted. 

Indications  for  the  Removal  of  Pulps. — The  question  of  remov- 
ing the  pulps  from  the  affected  teeth  in  this  class  of  cases  is  an 
important  one.  It  may  be  safely  stated  that  there  are  at  least  three 
indications  for  pulp  removal,  viz.:  (i)  where  the  pockets  are  deep 
and  the  infection  in  the  apical  area  has  left  the  pulp,  if  still  ahve, 
in  a  low  state  of  vitality;  (2)  where  it  is  necessary  to  adjust  some 


432 


PRACTICAL   DENTAL   THERAPEUTICS 


mechanical  appliance  (see  Figs.  105  and  106);  and  (3)  where  the 
tooth  is  so  acutely  sensitive  as  to  cause  constant  annoyance  to  the 
patient.  The  latter  condition  may  be  overcome  by  sealing  desensi- 
tizing paste  on  the  exposed  cementum  for  a  period  of  twenty-four 


Fig.  105. 


Fig.  106. 


Figs.  105  and  106. — This  is  a  case  where  there  was  an  abnormal  space  between  the 
lower  central  incisors,  about  the  width  of  one  tooth.  All  of  the  four  incisors  were  loose; 
the  left  central  hopelessly  so.  The  pulps  were  removed  from  the  two  lateral  and  right 
central  incisors,  and  the  canals  filled.  The  radiograph  for  Fig.  105  was  taken  Mar.  9, 
1916.  The  combination  bridge  and  retainer  was  adjusted  a  few  days  later.  The  radio- 
graph for  Fig.  106  was  taken  Nov.  30,  1916.  The  teeth  are  solid  and  comfortable,  and 
the  gums  pink  and  healthy. 


Fig.  107. — This  radiograph  shows  the  result  of  an  incorrect  diagnosis.  Pus  was 
flowing  from  between  the  two  central  incisors  and  from  between  the  left  central  and 
lateral  incisors.  The  condition  was  mistaken  by  the  dentist  for  an  alveolar  abscess; 
he  drilled  into  the  left  central  only  to  find  a  live  pulp,  which  was  removed  and  root 
filled.  In  the  operation  the  perfect  natural  crown  was  so  mutilated  that  a  Logan  crown 
was  subsequently  adjusted.  The  pus  still  continuing  to  flow,  an  attempt  was  made  to 
open  into  the  lateral,  as  the  skiagraph  shows  On  finding  another  live  pulp,  the  dentist 
became  discouraged,  to  say  nothing  about  the  patient,  and  referred  the  case.  The 
curettement  of  two  rather  stubborn  pyorrheal  pockets  effected  a  cure. 

hours,  or,  if  a  posterior  tooth,  by  cauterizing  the  exposed  cementum 
with  silver  nitrate  (see  p.  86).  The  transitory  sensitiveness  fol- 
lowing the  scaling  and  poUshing  of  the  teeth  may  generally  be  re- 
duced by  poHshing  the  surfaces  with  moist  sodium  bicarbonate, 


PYORRHEA   ALVEOLARIS 


433 


and  having  the  patient  rinse  the  mouth,  especially  before  retiring, 
with  a  warm  sodium  bicarbonate  solution. 

It  has  been  chnically  observed  by  White,  of  Nashville,  and  others 
that  the  removal  of  the  pulp  of  a  badly  affected  pyorrheal  tooth  is 
followed  by  a  more  rapid  response  to  the  local  treatment  of  the 
disease.  The  theory  has  been  advanced  that  in  the  removal  of 
the  pulp  the  entire  circulation  of  the  tooth  is  thrown  to  the  sluggish 
pericemental  membrane  and  thus  stimulation  is  brought  about. 
This  is  an  erroneous  idea,  for  Noyes  and  Broomell  have  clearly 
demonstrated  histologically  that  the  pericemental  membrane  is 
normally  well  suppHed  with  blood-vessels,  and  that  to  extirpate  the 
pulp  would  not  materially  affect  the  circulation  in  this  membrane. 
However,  there  are  many  cases  wherein  the  removal  of  the  pulp  is 
clearly  indicated — not,  however,  because  of  the  supposed  stimula- 
tion which  results,  but  because  of  its  low  state  of  vitaHty  and  ulti- 
mate death,  in  which  case  the  pyorrheal  condition  is  liable  to  be 
compHcated  by  the  presence  of  an  alveolar  abscess.  Fig.  107  illus- 
trates the  result  of  a  mistaken  diagnosis,  where  a  pyorrheal  condition 
was  mistaken  for  an  alveolar  abscess. 


Fig.  108.  Fig.  109. 

Fig.  108. — This  shows  an  exposed  molar  root,  such  as  is  frequently  encountered  in 
the  treatment  of  pyorrhea  alveolaris. 

Fig.  109. — This  shows  the  case  after  the  excision  of  the  root.  A,  excised  root; 
B,  cavity  after  removal. 

Denuded  Roots. — Whenever  a  single  root  of  a  multi-rooted  tooth 
is  practically  denuded  of  its  pericemental  attachment,  ^\-ith  the 
remaining  roots  in  fairly  good  condition,  the  badly  affected  root 
should  be  completely  excised.  Such  a  condition  is  illustrated  in 
Figs.  108  and  109.  (See  also  Figs,  no  and  in.)  This  necessitates, 
of  course,  the  removal  of  the  pulp  and  the  filling  of  the  root.  If 
two  roots  are  thus  affected,  the  tooth  had  better  be  extracted. 

The  use  of  local  anesthetics  in  connection  with  the  surgical  treat- 
28 


434  PRACTICAL   DENTAL   THEEAPEUTICS 

ment  of  pyorrhea  alveolaris,  is  not  advised,  as  a  rule.  To  further 
poison  the  tissues  by  actual  injection  when  they  are  already  in  a  low 
state  of  vitality  is  contraindicated,  and  the  slight  anesthesia  otherwise 
induced  is  too  often  obtained  only  at  the  expense  of  quite  as  much 
pain  as  J  the  careful  scaHng  and  curetting  with  the  proper  instru- 
ments would  produce.  The  parts  not  being  anesthetized  will  serve  as 
a  guide  to  the  careful  operator  in  locating  the  pockets,  when  the 
surgical  treatment  can  be  accomplished  with  a  minimum  amount 
of  injury  to  the  soft  parts  involved.  If  care  and  judgment  are  exer- 
cised, neither  the  pain  nor  the  discomfort  is  as  great  as  might 
naturally  be  supposed. 

After  the  surgical  treatment  is  completed,  the  prophylactic 
treatment  with  the  usual  instructions  should  be  given.  Patterson^ 
states,  "Experience  has  taught  that  the  time  spent  in  smoothing  the 
roots  is  well  worth  the  endeavor,  for  the  rapidity  and  permanency 
of  the  recovery  is  greatly  enhanced,  and  the  operation  cannot  be 
considered  completed  until  as  much  time  is  given  to  the  polishing 
as  to  the  removal  of  the  deposits." 

Elimination  of  Deep  Pockets. — It  is  always  best  in  deep  pockets, 
where  there  is  considerable  detachment  of  the  pericemental  mem- 
brane, to  surgically  eliminate  the  pocket,  as  shown  in  Figs.  112,  113, 
and  114.  This  is  done  by  using  a  local  anesthetic  solution  or  spraying 
the  part  with  ethyl  chlorid,  when  a  V-shaped  piece  of  the  gum  is 
removed.  Often  the  mere  slitting  of  the  gum  with  a  sharp  lancet 
will  suffice,  if  the  pocket  is  packed  to  prevent  the  edges  of  the 
wound  from  uniting.  It  is  far  better  to  have  an  exposed  root  sur- 
face free  from  infection,  than  to  retain  a  pocket  which  cannot  be 
kept  from  reinfection.  On  this  point,  Noyes^  says,  "It  is  important 
to  remember  that  whenever  the  fibers  (of  the  pericemental  mem- 
brane) have  been  stripped  from  the  surface  of  the  cementum,  they 
can  be  reattached  to  it  only  by  the  formation  of  a  new  layer  of 
cementum,  building  the  fibers  into  it.  This  is  certainly  possible  if 
the  conditions  are  properly  controlled,  but  the  cells  of  the  tissue 
must  be  in  a  normal  and  vitally  active  condition,  and  the  surface 
of  the  root  must  be  such  that  they  can  lie  in  physiologic  contact  with 
it.  The  cure  of  a  pyorrhea  case,  therefore,  becomes  a  biologic 
problem.  In  this  connection  it  is  important  to  remember  that  a 
surface  of  cementum  which  has  long  been  bathed  in  pus  may  be  so 
filled  with  poison  that  no  cell  can  lie  in  contact  with  it  and  perform 
its  function."     Hartzell  believes  that  these  surfaces  may  be  smoothed 

'  Johnson's  Operative  Dentistry,  p.  467. 

^  Dental  Histology  and  Embryology,  page  248. 


Fig.  iio. — The  picture  here  is  of  a  model  taken  from  a  case  after  the  mesiobuccal 
root  of  an  upper  first  molar  had  been  excised.  The  excised  root  is  shown  on  the  wire. 
With  a  little  care,  patients  may  keep  such  an  area  clean  and  the  tooth  may  be  saved 
for  a  number  of  years,  free  from  infection. 


Fig.  III. — The  picture  of  the  model  on  the  right  shows  a  case  where  the  lingual 
root  of  an  upper  first  molar  was  practically  denuded  of  its  pericemental  attachment. 
The  picture  of  the  model  on  the  left  shows  the  case  after  the  entire  root  had  been 
excised  and  the  tissues  had  healed.     The  excised  root  is  shown  on  the  wire. 


Fig.  112. — The  picture  of  this  model  shows   the   result   of  eliminating   the  pyorrhea) 
pocket  by  surgically  removing  the  overlying  soft  tissues. 


Fig.  113. — This  picture  shows  where  a  deep  pocket  on  the  distal  of  a  lateral  incisor 
has  remained  permanently  cured  for  a  number  of  years  after  surgically  eliminating  the 
pocket. 


Fig.  114. — These  are  pictures  of  models  of  cases  cured  by  surgically  eliminating  the 
pockets   about   the   affected   teeth. 


PYORRHEA   ALVEOLARIS  435 

by  proper  instrumentation  and  thus  left  free  from  bacteria  and  toxins, 
when  the  tissue  surrounding  the  pocket  is  caused  to  bleed,  filhng 
the  latter  with  a  sterile  blood-clot  and,  under  favorable  conditions, 
new  bone  is  formed.  This  may  be  .possible,  but  hardly  probable, 
considering  the  conditions  in  the  mouth. 

2.  Medicinal  Treatment. — The  medicinal  treatment  for  this  class 
of  cases  is  practically  the  same  as  for  the  preceding  class.  The 
pockets  should  be  washed  out  thoroughly  after  the  surgical  treat- 
ment. This  may  be  accomplished  with  either  the  spraying  apparatus 
or  water  syringe,  having  a  small  point  on  the  nozzle.  lodin,  because 
of  its  penetrating  and  stimulating  property,  is  especially  efficacious 
in  these  bone  affections.  The  case  generally  yields  nicely  when  the 
appHcation  of  the  local  astringent  remedy  is  made  at  intervals  of 
two  or  three  days.  The  time  of  making  the  subsequent  apphca- 
tions  should  gradually  be  lengthened,  and  in  about  two  or  three 
weeks  the  case  should  be  ready  for  the  patient  to  care  for  him- 
self. It  should  be  remembered  that  in  this  class  of  cases  the 
patient,  as  well  as  the  dentist,  is  confronted  with  a  more  serious 
proposition.  The  instruction,  therefore,  should  be  explicit  and  the 
progress  of  the  case  closely  watched. 

In  stubborn  pus  pockets  it  is  sometimes  necessary  to  thoroughly 
cauterize  the  area  involved  in  order  to  check  the  pus  formation.  For 
this  purpose  excellent  results  may  often  be  had  from  the  use  of  a 
25  or  50  per  cent,  solution  of  phenolsulphonic  acid.  This  is  a 
valuable  stimulating  agent,  and  may  be  appHed  deep  down  in  the 
pocket  with  a  Dunn  drop  applicator;  on  general  principles,  however, 
the  use  of  acids  in  the  treatment  of  this  disease  is  contraindicated, 
not  because  they  will  not  assist  Nature  in  effecting  a  cure,  but  because 
of  the  extreme  sensitiveness  which  they  produce.  Phenolsulphonic 
acid  is  an  exception  to  the  rule,  as  this  agent  does  not  leave  the  teeth 
sensitive.     It  is  generally  best  to  surgically  eHminate  such  pockets. 

Occasionally  the  pus  formation  will  persist  in  a  pocket  where  we 
are  reasonably  certain  that  the  ordinary  surgical  treatment  has  been 
thorough,  and  where  also  the  pocket  has  been  cauterized.  Here  we 
can  suspect  resorption  of  the  root  in  the  apical  area,  leaving  sharp, 
needle-like  points,  which  keep  up  the  irritation.  In  these  cases 
it  is  necessary  to  amputate  the  root-end  or  extract  the  tooth.  The 
author's  experience  with  replantation  as  a  last  resort  in  the  cure 
of  badly  affected  teeth  in  pyorrheal  or  abscessed  conditions  has  not 
been  encouraging.  For  permanent  results  it  is  absolutely  essential 
that  the  replanted  tooth  be  held  firmly  in  position  by  some  permanent 
appliance,  and  generally  its  extraction  and  the  insertion  of  an  arti- 


436  PRACTICAL   DENTAL   THERAPEUTICS 

ficial  tooth  is  far  more  sanitary  and  satisfactory.  It  is  not  a  question 
here  of  what  a  dentist  can  do  by  his  ingenuity  and  skill,  but  rather 
a  question  of  what  is  best  for  the  patient. 

Head,  of  Philadelphia,  a  few  years  ago,  brought  forth  the  use  of 
ammonium  hydrogen  fluorid  as  a  tartar  solvent  in  the  treatment  of 
pyorrhea  alveolaris.  The  solution  which  he  recommends  is  made 
as  follows :  Commercial  hydrofluoric  acid  is  completely  neutralized 
with  ammonium  carbonate  and  ammonium  fluorid  formed  which 
dissolves  in  the  water  present.  This  solution  is  filtered,  and  as  such 
has  little  chemic  action  on  the  so-called  "tartar"  on  the  teeth.  To 
make  the  more  active  acid  salt  solution  the  ammonium  fluorid  solu- 
tion is  now  evaporated  in  a  leaden  dish  to  one-half  of  its  original 
bulk,  an  equal  amount  of  hydrofluoric  acid  is  added,  and  the  whole 
again  evaporated  to  one-half  of  its  bulk.  The  resulting  solution  is 
ammonium  hydrogen  fluorid.  Great  care  must  be  exercised  in 
making  this  solution,  for  if  any  of  the  hydrofluoric  acid  is  left  free, 
its  action  would  produce  serious  results. 

Head  recommends  making  the  application  to  a  pyorrheal  pocket 
with  a  rubber  syringe  having  a  platinum  point  or  with  a  drop  appli- 
cator. The  claim  is  made  that  it  will  dissolve  the  deposit  without 
any  deleterious  effect  on  the  soft  tissues.  The  author  again  desires 
to  emphasize  the  precautions  to  be  observed  in  obtaining  a  solu- 
tion of  ammonium  hydrogen  fluorid  free  from  uncombined  hydro- 
fluoric acid,  for  a  burn  from  this  acid  is  at  best  a  stubborn  condition 
to  treat,  especially  in  the  mouth  where  there  is  always  danger  of  a 
mixed  infection.  For  various  reasons,  the  remedy  has  not  met  the 
earlier  expectations. 

Use  of  Emetin. — The  discussion  of  the  medicinal  treatment  of 
pyorrhea  alveolaris  would  not  be  complete  without  at  least  brief 
reference  to  the  use  of  ipecac  and  its  chief  alkaloid,  emetin. 

For  years  certain  preparations  of  ipecac  root  have  been  used 
empirically  in  the  treatment  of  amebic  or  tropical  dysentery,  an  ulcera- 
tive disease  of  the  intestines  due  to  the  presence  of  the  Endameha  histo- 
lytica. When  Barrett  and  Smith  discovered  the  universal  presence 
of  the  Endameha  buccalis  in  pyorrheal  pockets,  the  use  of  emetin 
at  once  suggested  itself.  Barrett  recommends  the  local  use  of  a  3^ 
per  cent,  solution  of  emetin  hydrochlorid,  as  stronger  solutions 
cause  irritation  of  the  soft  tissues.  The  solution  is  warmed  and 
introduced  into  the  pyorrheal  pocket,  using  an  ordinary  hypodermic 
syringe  with  a  flexible  blunt  needle.  In  addition  to  filling  the  definite 
pockets,  a  small  amount  of  the  solution  may  be  permitted  to  run  into 
the  interdental  spaces,  care  being  taken  to  avoid  any  chance  that 


PYORRHEA   ALVEOLARIS  437 

the  patient  will  swallow  the  remedy.  Emetin  is  a  prompt  emetic. 
Such  treatment  should  be  repeated  daily  for  five  or  six  days,  to  be 
followed  by  similar  treatments  every  other  day  for  as  many  times. 
According  to  Barrett  the  amebae  disappear  rapidly  and  are  rarely 
found  in  the  lesions  after  the  second  or  third  apphcation. 

Another  method  of  using  emetin  in  the  treatment  of  pyorrhea 
alveolaris  was  introduced  by  Bass  and  Johns,  after  their  discovery, 
almost  simultaneously  with  Barrett  and  Smith,  of  the  presence  of 
amebse  in  pyorrheal  lesions.  Their  original  method  consisted  of 
the  hypodermic  injection,  in  any  part  of  the  body,  usually  the 
arm,  of  3^  gr.  of  emetin  hydrochlorid  in  solution.  Ampules  con- 
taining the  proper  dosage  are  readily  obtainable.  These  injections 
were  made  daily  for  three  or  four  days,  repeating  the  treatment  on 
one  or  more  days  after  an  interval  of  three  to  ten  days.  Accord- 
ing to  these  authorities  amebas  disappear  from  all  lesions  in  practi- 
cally all  cases  after  six  days'  treatment. 

Still  another  method  of  using  emetin  in  the  treatment  of  this 
disease  is  the  oral  administration  of  alcresta  ipecac.  This  prepara- 
tion is  an  absorption  compound  of  the  ipecac  alkaloids,  emetin  and 
cephaeHn,  with  a  form  of  hydrated  aluminum  siHcate,  an  alkaloidal 
reagent  discovered  by  Professor  John  Uri  Lloyd,  of  Cincinnati, 
Ohio.  This  combination  prevents  the  alkaloids  from  being  dis- 
solved in  acid  or  neutral  solutions  and  permits  their  solution  in  alka- 
line media  only.  In  this  manner  these  alkaloids  pass  unchanged 
through  the  stomach,  which  prevents  entirely  the  nausea  and  vomit- 
ing caused  by  the  oral  administration  of  preparations  of  ipecac  in  any 
other  form.  This  means  that  the  alkaloids  are  physiologically  inert 
as  long  as  they  remain  in  the  stomach  and  become  active  when  set 
free  in  the  alkahne  intestinal  secretions,  where  they  not  only  act  on 
the  amebse  and  bacteria  locally  in  the  intestine,  but  whence  they  are 
absorbed  and  carried  by  the  blood-stream  to  the  alveolar  lesions, 
acting  there  also  upon  the  infecting  organisms. 

The  tablets  of  alcresta  ipecac  should  be  given  while  the  surgical 
treatment  of  the  case  is  in  progress  or  even  preceding  it.  Two  tab- 
lets in  one-half  glass  of  water  one-half  to  one  hour  before  meals 
and  on  going  to  bed  is  the  proper  dosage  to  be  continued  for  a 
period  of  five  days,  when  the  drug  should  be  discontinued  for  about 
a  week,  at  the  end  of  which  time  a  second  course  may  be  prescribed. 
In  some  cases  there  will  be  a  slight  looseness  of  the  bowels  after  the 
fifth  or  sixth  day.  It  is  seldom  necessary  to  discontinue  the  admin- 
istration of  the  drug  on  this  account. 

The  author  has  used  emetin  in  every  manner  in  whichjt  has  been 


438  PRACTICAL   DEXTAL   THERAPEUTICS 

suggested,  both  in  college  and  in  private  practice;  and  I  can  say- 
that  there  is  no  longer  any  doubt  in  my  mind  about  the  efficacy  of 
the  drug.  Used  locally,  as  suggested  by  Barrett  and  Smith,  in  my 
hands  the  remedy  has  been  disappointing;  but  the  results  are  surely 
noticeable  when  the  drug  is  internally  administered,  as  suggested  by 
Bass  and  Johns.  As  stated  above,  there  are  two  ways  in  which  this 
may  be  accompUshed :  By  the  hypodermic  injection  of  emetin  hydro- 
chlorid,  and  by  the  mouth  administration  of  alcresta  ipecac.  So  far 
as  I  have  been  able  to  observe,  there  is  little,  if  any,  difference  in  the 
results  obtained  by  these  two  means  of  getting  the  drug  into  the 
circulation  whence  the  blood-stream  carries  it  to  the  alveolar  lesions. 
Because  of  the  ease  of  accompHshment,  and  also  because  of  the 
local  effects  of  the  drug  on  the  organisms  in  the  intestines,  the  mouth 
administration  is  far  preferable,  and  the  results  equally  as  good, 
if  not  better. 

The  present  opinion  of  the  author  regarding  the  "emetin  treat- 
ment" for  pyorrhea  alveolaris  is  that  the  remedy  is  not  a  specific  for 
the  disease.  In  itself,  used  as  many  physicians  have  used  it,  without 
the  all-important  local  treatment,  in  my  hands  it  will  not  cure  the 
disease;  but  used  internally,  as  the  surgical  treatment  is  undertaken 
and  accomplished,  the  inflammation  subsides  more  readily,  the  gums 
resume  their  normal  color  and  tone  more  quickly,  and  the  teeth  and 
general  mouth  conditions  are  more  comfortable  than  when  the  drug  is 
not  administered.  I  beheve  the  future  will  demonstrate  that  emetin 
when  internally  administered  has  some  therapeutic  effect,  other  than 
its  amebicidal  action,  which  makes  its  use  valuable  in  the  treatment 
of  certain  mouth  conditions.  It  may  be  its  hemostatic  action  upon 
the  blood. 

The  remedy  is  equally  efiSicacious  for  flabby  and  bleeding  gums 
and  aU  other  inflammatory  conditions  resulting  from  local  irritants, 
and  tending  toward  pyorrhea.  It  must  be  remembered,  however, 
that  no  remedy  should  be  administered  for  such  conditions  wdthout  a 
thorough  prophylactic  treatment  of  the  mouth.  When  Bass^  made 
the  statement  that  95  per  cent,  of  all  adults  examined  by  him  had 
pyorrhea  alveolaris,  he  must  have  used  the  term  in  a  broad  sense 
and  included  gingivitis  and  all  other  inflammatory  mouth  conditions. 
Strictly  speaking  these  conditions  should  not  be  classed  as  pyorrhea. 

Use  of  Mercury  Succinimid. — The  effects  of  mercury  succinimid, 
when  internally  administered,  upon  pyorrheal  lesions  was  noticed 
wholly  by  chance  by  Dr.  Paul  G.  White,^  assistant  dental  surgeon, 

^  Journal  of  the  American  Medical  Association,  Feb.  13,  1915. 
*  Dental  Cosmos,  April,  1915. 


PYORRHEA   ALVEOLARIS  439 

U.S.N.,  at  the  Portsmouth  Navy  Yard.  In  relating  his  experience 
White  says:  "Two  patients,  who  had  been  under  local  treatment  for 
pyorrhea  alveolaris,  presented  themselves  upon  different  days  with 
gums  swollen  and  exquisitely  tender,  and  often  with  free  saHvation. 
Being  unable  to  account  for  such  conditions,  which  occurred  at 
regular  intervals,  the  patients  were  questioned,  and  the  fact  that 
they  were  also  being  treated  for  other  troubles  at  the  same  time  by 
Dr.  Barton  L.  Wright,  U.S.N.,  senior  surgeon  at  the  Yard,  was 
brought  to  light.  Investigations  showed  that  both  patients  were 
being  given  deep  muscular  injections  of  mercury  at  regular  intervals, 
and  that  the  changes  in  the  gum  tissues  and  their  hypersensitiveness 
were  usually  most  prominent  on  the  second  day  after  treatment. 
The  surprisingly  quick  cessation  of  the  pus  flow  from  the  pockets  and 
the  corresponding  return  to  normal  of  the  gum  tissues  led  to  the 
introduction  of  mercury  succinimid  in  other  cases."  These  authors 
report  startling  results  in  a  number  of  cases.  The  use  of  the  remedy, 
as  yet,  has  not  been  demonstrated  to  be  practical,  nor  is  it  of  sufiS.- 
cient  value  to  be  employed  generally  in  the  treatment  of  the  disease. 
What  the  future  holds  forth,  remains  to  be  seen.  There  is  no  longer 
any  doubt  in  the  minds  of  those  who  have  given  serious  study  to 
the  relation  of  pyorrhea  alveolaris  to  systemic  disease,  regarding  the 
effects  of  syphilis  on  the  supporting  or  investing  structures  of  the 
teeth.  It  may  be  that  mercury  will  prove  most  beneficial  in  the 
treatment  of  mouth  conditions  when  known  to  be  associated  with 
a  specific  history. 

Use  of  Vaccines. — The  raising  of  the  opsonic  index  has  been  sug- 
gested as  a  means  of  combating  pyorrhea  alveolaris,  as  has  also  the 
use  of  specific  vaccines  (Hecker  and  others).  The  efficacy  of  these 
methods  has  not  been  sufficiently  demonstrated  to  merit  their  discus- 
sion in  a  work  on  "practical  therapeutics"  at  this  time.  In  this  con- 
nection, however,  it  should  be  remembered  that  we  should  never 
be  in  too  great  haste  to  remove  foci  of  infection  when  the  patient 
is  systemically  involved.  In  these  cases,  several  pyorrheal  pockets 
should  not  be  curetted  at  one  sitting,  nor  should  several  involved 
teeth  be  extracted  at  one  time,  on  account  of  the  reaction  which 
frequently  follows  the  disturbance  of  areas  of  infection.  It  is  best 
in  all  such  cases  to  confine  the  operation  to  one  or  two  teeth. 

It  is  to  be  hoped  the  true  cause  of  pyorrhea  alveolaris  will  soon 
be  discovered,  when  the  medicinal  treatment  can  be  instituted  along 
more  rational  fines  or,  what  would  be  better,  such  prophylactic 
measures  inaugurated  that  the  disease  might  be  prevented.  In 
our  present  state  of  knowledge  it  must  be  said  that  too  much 


440 


PRACTICAL   DENTAL   THERAPEUTICS 


dependence  should  not  be  placed  upon  drugs,  for  at  this  time  there 
is  no  known  specific  for  the  cure  of  the  disease. 

Where  the  loss  of  tissues  has  been  extensive  and  the  teeth  are  so 
loose  as  to  interfere  with  their  usefulness  in  mastication,  the  correct 
treatment  necessarily  includes  the  making  of  mechanical  appliances 
for  their  support. 

3.  Mechanical  Treatment. — The  importance  of  what  the  author 
has  chosen  to  call  the  mechanical  treatment  of  the  disease  under 
consideration  has  previously  been  emphasized.  A  detailed  de- 
scription of  the  method  of  making  the  various  mechanical  appli- 


FiG.  115. — This  shows  loosened  lower  anterior  teeth,  temporarily  wired  with  a  26 
gauge  platinoiridium  wire,  to  hold  the  teeth  during  the  scaHng  process,  after  which  a 
permanent  retainer,  as  illustrated  in  Figs.  116  and  117,  was  adjusted. 


Fig.  116.  Fig.  117. 

Fig.  116 — This  shows  the  retainer  in  wax  with  the  sprue  inserted  ready  to  be  in- 
vested for  casting. 

Fig.  117. — This  shows  the  completed  appliance  set  on  the  model. 

directions  for  making 

A  modehng  compound  impression  is  taken  of  the  cutting  edge  and  upper  lingual 
third  of  the  teeth  to  be  included  in  the  appliance.  From  this  impression  a  model  is 
made  with  a  good  investment  material.  It  is  best  to  let  it  set  over  night,  when  the 
modeling  compound  can  be  removed  by  using  dry  heat.  Care  should  be  exercised  notjto 
chip  |the  margins  of  the  investment  teeth.  On  this  model  the  retainer  can  be  made 
in  wax  just  as  it  is  desired  when  completed.  The  model  is  trimmed  so  it  can  be 
put  into  a  casting  flask,  the  sprue  inserted  and  it  is  ready  for  investing  (Fig.  116). 
After  casting,  it  is  finished  and  set  in  the  usual  manner  (Fig.  117). 


ances  is  not  properly  included  in  a  work  of  this  character.  The 
proper  apphance  for  holding  loose  teeth  in  the  jaw  will  naturally 
suggest  itself  to  the  ingenious  dentist.  They  consist  of  a  combina- 
tion of  inlays,  crowns  and  bridges,  the  so-called  splints,  and  various 
retainers.  For  the  benefit  of  the  beginner  a  splint  suggested  by  Dr. 
C.  L.  Hine,  of  Tuscola,  111.,  for  loose  teeth,  the  pulps  of  which  need 
not  be  devitalized,  is  illustrated  and  briefly  described  in  Figs.  115, 
116  and  117.     On  the  following  pages  the  reader  will  find  Figs.  118 


PYORRHEA   ALVEOLARIS 


441 


to  130,  inclusive,  with  descriptions  which  were  furnished  the  author 
by  Dr.  Lee  K.  Stewart,  of  Chicago,  and  explain  fully  his  method  of 
treating  the  conditions  under  consideration  from  the  mechanical 
viewpoint.  It  should  be  borne  in  mind  that  no  tooth  should  be 
retained  in  the  mouth  that  cannot  be  kept  free  from  infection. 


Fig.  118  a. 


Fig.  1x8  B. 


Fig.  119  A. 


Fig.  119  B.  Fig.  120  A.  Fig.  120  B. 


Fig.  121  a. 


Fig.  121  B. 


Fig.  121  C. 


Fig.  122. 


Fig.  118. — "A"and"B".  Loose  teeth  from  which  the  pulps  have  been  removed, 
the  canals  filled,  prepared  for  insertion  of  soft  platinum  wire  and  ready  for  the  wax 
pattern  or  modeling  compound  impression. 

Fig.  119. — "A"  and  "B".  One  or  more  teeth  with  soft  platinum  wire  in  position. 
The  exposed  end  is  barbed  to  hold  either  in  the  wax  pattern  or  the  impression  material. 
The  operator  may  prepare  the  wax  model  for  casting  directly  upon  the  tooth,  or  upon 
the  models. 

Fig.  120. — "A"  and  "B".     Modeling  compound  impressions  of  one  or  more  teeth. 

Fig.  121. — "A",  "B"  and  "C".  Models  of  one  or  more  teeth  made  from  impres- 
sions, waxed  and  ready  for  investing  for  casting.  Notice  the  pin  has  been  placed  to 
direct  the  flow  of  gold  by  rather  than  at  the  model.  Models  made  of  equal  parts  of 
plaster  and  silica. 

Fig.  122. — Double  wax  model  made  directly  upon  the  teeth  and  ready  for  invest- 
ment. 


442 


PRACTICAL   DENTAL   THERAPEUTICS 


Fig.  123. 


Fig.  124. 


Fig.  123. — Method  of  investing. 

Fig.  1 24. — Two  castings  in  position  and  ready  for  the  impression.  Notice  that  the 
exposed  end  of  soft  platinum  wire  has  not  been  cut  off.  Do  not  attempt  to  assemble 
more  than  two  at  one  time,  and  take  the  impression  of  the  parts  ready  to  be  united  either 
with  a  small  piece  of  modeling  compound  or  just  a  little  plaster.  Fill  the  impression 
with  ordinary  soldering  investment,  separate  and  solder. 

Fig.  125. — Two  castings  soldered.  Continue  in  this  manner,  making  single,  double 
or  larger  castings,  either  from  models  or  by  carving  the  wax  upon  the  natural  tooth. 


Fig.  127. 

Fig.  126.— Finished  case  with  pins  well  barbed.  Do  not  cut  barbs  opposite  each 
other;  and  remember  not  to  cut  off  the  exposed  ends  of  soft  platinum  wire  until  the  case  is 
ready  for  the  final  pohshmg.  No  gold  should  be  noticeable  in  the  patient's  mouth. 
The  larger  barbs  will  prevent  a  tooth  that  has  been  shortened  from  dropping  below  the 
others. 

Fig.  127. — A  case  with  loss  of  the  lateral  incisor. 


Fig.  128. — Retaining  appliances  replacing  lost  incisor.  Many  cases  present  where 
one  or  more  teeth  have  been  lost  and  the  others  are  very  loose.  This  appliance  will 
support  the  loose  ones  and  replace  the  lost  ones. 


PYORRHEA   ALVEOLARIS 


443 


Fig.  129.  Fig.  130. 

Fig.  129. — ^Labial  view. 

Fig.  130. — ^Lingual  view. 

This  method  can  be  used  in  any  place  in  the  mouth  to  support  loose  teeth  and  to 
carry  bridged  ones. 

Where  it  is  desirable  to  retain  the  pulps,  use  one  or  two  short  soft  platinum  pins  in 
each  tooth  and  prepare  nearly  parallel  pits  as  far  away  from  the  pulp  as  possible. 
Before  placing  the  appliance,  barb  the  pins  well  and  undercut  the  cavities.  (L.  K. 
Stewart.) 

CLASS  m 

In  considering  the  therapeutics  of  this  class  of  cases  from  the 
dental  viewpoint  it  can  be  stated  that  the  treatment  is  both  local 
and  general. 

1.  Local  Treatment. — The  local  treatment  involves  practically 
the  same  surgery,  drugs  and  remedies,  and  mechanical  appliances 
as  in  the  preceding  classes,  modified  only  to  meet  the  conditions  as 
found.  To  be  effective  and  permanent  the  treatment  by  the  dentist 
must  be  given  conjointly  with  the  general  treatment  by  the  physician 
in  charge. 

2.  General  Treatment. — Whenever  the  local  condition  in  the 
mouth  seems  to  be  aggravated,  if  not  caused,  by  some  of  the  systemic 
diseases  elsewhere  mentioned,  it  is  the  plain  duty  of  the  dentist  to 
refer  the  patient  to  his  family  physician  for  the  general  treatment. 
In  fact,  it  is  almost  useless  to  undertake  the  local  treatment  unless 
measures  are  simultaneously  instituted  for  the  correction  of  the 
systemic  disease;  but  when  the  physician  and  dentist  work  together 
in  harmony,  it  is  surprising  what  great  relief  can  be  given  the  patient 
by  the  proper  local  treatment,  for  the  mouth  in  many  instances  is  in 
a  hideous  condition.  In  all  cases  wherein  some  systemic  complica- 
tion is  suspected,  the  dentist  should  not  fail  to  have  the  urine 
examined  for  at  least  such  abnormal  constituents  as  albumin  and 
sugar.  With  a  little  practice  the  dentist  may  readily  make  these 
tests  himself.  A  brief,  but  practical  outline  for  the  examination 
of  the  urine  will  be  found  on  p.  468. 

In  conclusion,  I  desire  to  state  that  it  is  a  pleasure  to  work  for 
pyorrheal  patients.  In  many  instances  they  have  been  informed 
that  nothing  could  be  done,  and  that  they  must  soon  lose  their  teeth; 
therefore,  in  most  cases,  they  appreciate  fully  your  every  effort. 


NEURALGIA 

GENERAL  CONSIDERATIONS 

Neuralgia  may  be  defined  as  a  severe  paroxysmal  pain  in  the 
area  of  distribution  of  a  nerve,  or  along  its  course;  and,  according  to 
Barrett,  true  neuralgic  pain  is  principally  confined  to  the  afferent 
or  sensory  nerves,  but  it  may  be  of  a  reflex  character  and  hence  have 
its  origin  in  the  efferent  or  motor  nerves.  It  is  not  a  disease  in  itself, 
but  is  rather  a  manifestation  of  a  disease  or  perverted  function; 
therefore,  the  conditions  which  may  cause  neuralgia  are  many  and 
varied;  and,  for  convenience  in  study,  they  may  be  classified  as 
follows : 

I.  General  Diseases. 

1.  Those  Which  Lower  Vital  Resistance. — This  class  includes 
anemia,  or  other  diseases  which  interfere  with  such  vital  functions 
of  the  body  as  the  circulation,  respiration,  secretion,  digestion, 
assimilation  and  ehmination, 

2.  Those  Which  Produce  Foreign  or  Abnormal  Substances  in  the 
Blood. — This  includes  syphilis,  gout,  rheumatism,  diabetes,  nephritis, 
malaria,  chronic  pyemias  or  any  foci  of  infection,  metallic  poisoning, 
etc. 

II.  Local  Diseases. 

1.  Those  Which  Cause  Reflex  Peripheral  Irritation. — In  this  class 
are  included  diseases  of  the  teeth,  eyes,  ears,  stomach,  uterus,  and 
ovaries. 

2.  Those  Which  Produce  Pressure. — This  includes  various  tumors, 
and  especially  such  abnormal  growths  as  occur  within  bony  canals 
through  which  nerve-trunks  pass. 

3.  Chronic  Inflammation  of  the  Nerve-sheath  or  of  the  Nerve 
Itself. — This  includes  neuritis,  or  actual  diseased  conditions  of  the 
nerve. 

III.  Certain  Intractable  Cases. 

This  class  includes  a  large  number  of  cases  of  neuralgia  for  which 
no  cause  can  be  found. 

The  neuralgias  which  generally  come  under  the  observation  of 
the  dental  practitioner  are  chiefly  those  manifested  in  the  area  of 
distribution  or  along  the  course  of  the  fifth  cranial  nerve,  and  are 
accordingly  called  facial,  trifacial  or  trigeminal  neuralgia. 

444 


NEUEALGIA  445 

FACIAL  NEURALGIA 

There  are  many  local  conditions  in  and  about  the  teeth  which 
may  cause  facial  neuralgia.     Chief  among  them  are: 

1.  Pulpitis. 

2.  Pulp  nodules,  partially  calcified  pulps,  and  secondary  dentin. 

3.  Pericementitis. 

4.  Cementosis. 

5.  Deposits  on  the  roots  of  teeth. 

6.  Infections  about  the  roots  of  teeth. 

7.  Exposed  dentin  and  cementum. 

8.  Impacted  teeth. 

9.  Faulty  occlusion. 

THERAPEUTICS 

The  first  essential  in  the  treatment  of  neuralgia  due  to  diseases 
of  the  teeth  is  to  ascertain  the  cause  and  remove  or  correct  it,  if 
possible.  As  Harlan  says:  "The  dentist  should  consider  no  time 
lost  in  an  endeavor  to  find  the  cause  of  facial  neuralgia."  It  is 
essential  here,  as  in  all  treatment  cases,  to  make  a  correct  diagnosis. 
In  most  cases  the  symptoms  are  of  the  subjective  variety  and  a 
correct  diagnosis  is  often  difficult  to  make.  It  is  necessary  often- 
times to  take  into  consideration  the  diseases  outlined  in  the  classi- 
fication on  the  preceding  page;  and  it  is  also  well  to  remember  that 
women  are  especially  prone  to  neuralgia  during  the  period  of  the 
so-called  "change  of  life."  Fortunately,  however,  by  means  of 
radiography  many  of  the  conditions  mentioned  as  being  productive 
of  facial  neuralgia  may  be  positively  diagnosed.  Illustrations  of 
several  of  these  conditions  are  found  on  the  following  page  in  Figs. 
131,  132,  133,  134,  135  and  136.  The  late  Dr.  J.  N.  Grouse,  of 
Chicago,  reported  an  interesting  case  in  his  practice  which  occurred 
before  radiography  was  known  (see  Figs.  137,  138,  139  and  140).  The 
author  desires  to  emphasize  the  importance  of  ascertaining,  if  at  all 
possible,  the  cause  of  the  neuralgia,  for  upon  this  depends  largely 
the  method  of  applying  our  therapeutics.  In  radiographing  the 
teeth  for  possible  causes  of  neuralgia,  it  is  well  always  to  radiograph 
the  areas  where  teeth  have  been  extracted.  In  this  way  many  an 
obscure  cause  may  be  located  in  a  root-end  which  had  been  left 
and  which  has  a  low  grade  of  infection  associated  with  it.  With 
the  cause  known,  the  treatment  is  of  two  kinds — medicinal  and 
surgical. 


446 


PRACTICAL   DENTAL   THERAPEUTICS 


Fig.  131. — This  radiograph  shows  an  impacted  lower  third  molar,  frequently  the  cause 

of  facial  neuralgia. 


Fig.  132. 


Fig.  133. 


Fig.  134. 


Fig.  135. 


Figs.  132,  133,  134  and  135. — These  all  show  cementosed  roots,  the  cause  of  facial 

neuralgia. 


Fig.  136. — This  shows  a  lower  third  molar  coalesced  to  and  between  the  roots  of  the 

lower  second  molar. 


NEURALGIA 


447 


I.  Medicinal  Treatment. — The  medicinal  treatment  of  facial 
neuralgia  may  be  subdivided  into  local  and  general. 

1.  Local  Treatment. — There  are  many  drugs  and  remedies 
which  act  favorably  upon  the  sensory  nerve-endings,  and  are, 
therefore,  efficacious  in  the  local  medicinal  treatment  of  this  disorder. 


Fig.  137. 


Fig.  138. 


Fig.  139. 


Fig.  140. 


The  above  figures  are  illustrations  of  perfectly  sound  teeth  which  were  extracted 
from  one  mouth.  The  symptoms  were  different  from  those  of  any  other  case  with  which 
I  have  had  to  deal.  When  the  patient  first  presented,  in  the  middle  of  the  night,  he 
was  suffering  such  severe  paroxysms  of  pain  that  during  one  of  the  attacks  he  dropped 
to  the  floor  almost  senseless.  The  attacks  were  of  short  duration,  but  several  occurred 
before  I  could  learn  what  the  trouble  was.  Directly  after  one  of  these  spells,  by  tap- 
ping the  teeth  on  the  side  where  the  pain  was  most  severe,  I  found  slight  sensitiveness; 
particularly  was  this  so  of  the  first  upper  bicuspid,  although  the  pain  radiated  all  over 
the  head.  I  attempted  to  drill  into  this  tooth  and  found  the  canal  obliterated,  so  I 
extracted  it  (Fig.  137).  Notice  also  the  cementosed  root.  The  history  of  the  other  teeth 
(Figs.  138,  139  and  140)  is  similar,  except  that  I  could  locate  the  trouble  with  less  diflS- 
culty  after  the  first  experience;  then,  too,  the  disease  had  not  progressed  quite  so  far 
before  the  teeth  were  extracted.  I  lost  track  of  the  patient  and  do  not  know  whether 
he  had  further  trouble  or  not.     (/.  N.  Crouse.) 


The  author's  dental  Uniment  mentioned  in  connection  with  non- 
septic  pericementitis  (p.  362)  will  often  give  excellent  results,  or 
any  of  the  follpwing  remedies  may  be  prescribed: 


gr.  XXX  (2.0  Gm.) 


I^ — Mentholis, 
Alcoholis, 

Etheris,  aa    f5vi  (24.0  mils) 

Chloroformi,  q.  s.  ad.  f5iij  (90.0  mils) — M. 

Sig. — Apply  by  vigorous  rubbing  or  massage  over  the  area  of 
distribution  of  the  affected  nerve,  or  along  its  course. 


I^ — Camphorse  (gum), 
Tincturae  aconiti, 
Linimenti  saponis, 
Sig. — Use  as  above. 


3ij  (8.0  Gm.) 

foj  (30.0  mils) 

s.  ad.  fSiij  (90.0  mils) — M. 


448  PRACTICAL   DENTAL   THERAPEUTICS 

W.  H.  Truman  suggests  the  following: 

I^ — Camphorae  (gum),  5j  (4-o  Gm.) 

Etheris,  f5ij  (8.0  mils) 

Alcoholis,  f§j  (30.0  mils) 

Chloroformi,  q   s.  ad.  fgiij  (90.0  mils) — M. 
Sig. — Use  as  above. 

The  various  liniments  here  given  have  practically  the  same  thera- 
peutic effect — that  of  a  sedative  upon  the  peripheral  sensory  nerves. 

In  cases  where  the  pain  comes  from  pericementitis  or  from  a 
developing  abscess  associated  with  the  upper  anterior  teeth,  it  may 
be  stopped  in  many  instances  like  magic  by  spraying  the  posterior 
nares  with  alcohol  and  water,  as  suggested  by  Keefe  (see  p.  368). 

Electricity  is  often  of  great  value.  Marshall  suggests  applying 
the  positive  pole  of  a  galvanic  battery  to  the  painful  spot,  when  a 
current  of  from  one  to  three  milliamperes  is  applied  for  from  two  to 
five  minutes.  Freezing  the  area  with  ethyl  chlorid  will  frequently 
afford  much  relief,  especially  in  cases  of  acute  pericementitis. 

2.  General  Treatment. — The  general  medicinal  treatment  in- 
volves the  administration  of  drugs  systemically.  If  certain  drugs  are 
indicated  for  the  correction  of  some  systemic  derangement  which  is 
causing  reiiexly  the  facial  neuralgia,  as,  for  instance,  iron  compounds 
in  anemia,  quinin  in  malaria,  mercury  and  iodids  in  syphiHs,  etc. 
they  had  better  be  prescribed  by  the  family  physician.  Here  again 
is  a  condition  wherein  the  best  results  from  the  treatment  are  ob- 
tained only  when  both  the  family  dentist  and  the  physician  work  in 
harmony.  Cases  have  been  authentically  reported  where  physicians 
had  treated  patients  systemically  for  neuralgia  for  months  without 
effect,  when  ultimately  the  case  was  cured  instantly  by  the  dentist  in 
relieving  some  local  condition  about  the  teeth;  while,  on  the  other 
hand,  dentists  have  been  known  to  keep  patients  suffering  for  months 
in  an  endeavor  to  locate  the  cause  about  the  mouth,  when  ultimately 
the  correction  of  some  systemic  trouble  cured  the  local  neuralgia. 

While  patients  should  be  referred  to  the  family  physician  for  the 
general  treatment  of  constitutional  diseases,  it  is  not  only  the  privi- 
lege but  the  plain  duty  of  dentists  to  prescribe  internal  drugs  for  the 
reUef  of  pain  while  the  cause  of  the  neuralgia  is  being  searched  for 
and  removed.  It  is  true  that  this  involves  a  knowledge  of  drugs 
and  their  uses,  but  surely  this  is  not  too  much  to  expect  of  the  trained 
dental  practitioner  of  to-day.  The  classes  of  drugs  indicated  for  the 
control  of  pain  are  the  hypnotics  or  general  anodynes  or  analgesics. 
Several  prescriptions  are  here  given.  The  practitioner  can  select 
the  one  which  best  seems  to  suit  the  case  at  hand. 


NEURALGIA  449 

I^ — Pulveris  acetanilidi  comp.,  gr.  xx  (1.3  Gm.) 

Fiat  chartnlse  No.  iv. 
Sig. — Take  one  powder  every  hour  until  two  or  three  are 
taken;  if  not  relieved  after  two  or'three  hours,  take 
the  remaining  one  or  two. 

In  cases  of  neuralgia  of  rheumatic  origin  phenacetin  may  be  com- 
bined with  salophen  and  codein  sulphate  to  control  the  pain.  A 
prescription  follows: 

I^ — Phenacetini, 

Salophen,  aa     gr.  xx  (1.3  Gm.) 

Codeinae  sulphatis,  gr.  j  (0.06  Gm.) — M. 

Fiat  chartulae  No.  iv. 
Sig. — Take  one  powder  every  two  hours. 

Note. — This  prescription  will  require  a   Federal  blank,  with    the  prescriber's 
registered  number. 

When  the  neuralgia  is  associated  with  nervous  headache  the 
following  prescription  may  be  given: 

I^ — Caflfeinae  citratis,  gr.  xij  (0.8  Gm.) 

Phenacetini,  3ss  (2.0  Gm.) — M. 

Fiat  chartulae  No.  vj. 
Sig. — Take  one  powder  every  two  hours  untU  relieved. 

Occasionally  patients  do  not  like  to  take  a  powder,  preferring 
a  liquid  preparation.  In  these  cases  we  can  prescribe  antipyrin  in 
solution  with  an  aqueous  vehicle,  for,  unhke  acetanilid  and  phen- 
acetin, this  drug  is  soluble  in  water.  Sometimes  it  is  advisable  to 
combine  the  coal-tar  analgesics  with  a  bromid;  a  prescription  for 
such  a  combination  is  here  given: 

I^ — Antipyrinae,  5ss  (2.0  Gm.) 

Sodii  bromidi,  3j  (4-o  Gm.) 

Glycerini,  f5ss  (15.0  mils) 

Aquae  cinnamomi,  q.  s.  ad.  f5ij  (60.0  mils) — M. 

Sig. — Take  a  dessertspoonful  three  times  a  day,  and  oftener  if 
conditions  necessitate. 

Sometimes  the  coal-tar  analgesics  fail  to  produce  the  desired 
effect,  in  which  case  there  is  always  one  drug  that  can  be  relied  upon 
to  control  the  pain,  and  that  is  morphin.  This  drug  is  truly  indi- 
cated for  the  control  of  pain  from  whatever  source  and  may  be  given 
here  in  ^  gr.  (0.008  Gm.)  dose,  but  under  no  conditions  should  a 
prescription  be  written  for  the  drug.  Many  patients  are  in  the 
habit  of  keeping  a  copy  of  the  prescription,  and  when  the  remedy 


450  PRACTICAL   DENTAL   THERAPEUTICS 

works  well  in  a  certain  case  they  often  get  the  prescription  refilled 
for  themselves  or  friends  on  the  least  provocation.  In  the  case  of- 
morphin  this  might  innocently  lead  to  the  "habit."  Tablets  con- 
taining the  usual  dose  (3^  gr.-o.oo8  Gm.)  may  be  kept  on  hand, 
and,  if  necessary,  two  such  tablets  may  be  given  by  the  stomach 
within  one-half  hour,  and  then  the  patient  can  take  one  tablet 
home — never  more  than  one,  if  two  have  been  given  at  the  office — 
which  can  be  taken  in  the  course  of  an  hour,  if  not  relieved.  It  is 
necessary  to  keep  a  record  when  using  drugs  which  come  under  the 
"Federal  Antinarcotic  Law."  Fortunately,  it  is  seldom  necessary 
for  the  dentist  to  prescribe  opium  or  its  alkaloids;  but  when  indicated, 
in  their  judgment,  they  have  the  legal  right  to  prescribe  any  drug 
to  relieve  suffering  humanity. 

Of  the  newer  synthetic  products,  pyramidon  is  one  of  the  best. 
This  may  be  prescribed  in  five-grain  (0.3  Gm.)  tablets  every  two  hours 
until  relief  is  obtained,  or  until  four  or  five  tablets  have  been  taken. 
It  should  be  remembered  that  no  drug  should  be  taken  continuously 
for  the  relief  of  pain.  These  remedies  are  only  intended  to  control 
the  pain  until  the  cause  is  corrected  or  removed. 

When  the  patient  is  unable  to  sleep,  chloral  hydrate  or  butyl- 
chloral  hydrate  may  be  prescribed.  The  fifth  nerve  is  supposed  to 
be  especially  sensitive  to  the  influence  of  butyl-chloral  hydrate. 
A  prescription  follows: 

I^ — Butyl-chloralis  hydratis,  5j  (4-o  Gm.)  . 

Fiat  capsulis  No.  xij. 
Sig. — Take  one  capsule  every  three  hours  until  four  are  taken. 

In  cases  where  a  tonic  is  indicated,  as  in  anemia,  the  syrup  or 
glycerite  of  iron,  quinin,  and  strychnin  phosphate  (N.F.)  may  be 
given.     A  prescription  for  the  syrup  follows: 

I^ — Syrupus  ferri,  quininje  et  strych- 

ninae  phosphatis,  fSiij  (90.0  mils) 

Sig. — Take  a  teaspoonful  in  water  before  meals. 

Where  the  neuralgia  is  of  malarial  origin,  quinin  is  indicated. 
An  excellent  prescription  follows : 

^I^ — Quininae  valerianatis,  gr.  xviij  (1.2  Gm.) 

Extracti  hyoscyami,  gr.  iv  (0.25  Gm.) 

Extracti  cinchonae,  gr.  viij  (0.5  Gm.) — M. 

Fiat  capsulae  No.  xij. 
Sig. — Take  one  capsule  before  meals  and  on  retiring. 

'  Taken  from  the  Dental  Cosmos. 


NEURALGIA  45 I 

It  will  be  noticed  that  only  a  few  doses  have  been  prescribed  in 
any  of  the  above  prescriptions.  This  precaution  has  been  taken 
because  some  of  these  patients  suffer  untold  agony;  in  fact,  they 
may  be  considered  temporarily  demented,  and  no  matter  how 
specific  your  verbal  and  written  directions  have  been,  they  may  ignore 
your  directions  entirely  and  take  one  dose  after  another  on  the 
general  principle  that  "if  a  little  is  good,  more  is  better,"  until  they 
have  taken  such  a  quantity  as  may  result  in  an  overdose.  Therefore, 
it  is  well  for  dentists,  especially,  to  be  careful  in  this  respect. 

n.  Surgical  Treatment. — The  surgical  treatment  often  involves 
major  surgery,  for  a  discussion  of  which  see  works  on  Oral  Surgery.^ 

TIC  DOULOUREUX 

The  discussion  of  facial  neuralgia  would  indeed  be  incomplete 
without  at  least  brief  mention  of  tic  douloureux,  so  named  by  Trous- 
seau, a  Frenchman.  The  condition  frequently  results  from  chronic 
irritation  of  the  filth  cranial  nerve.  The  pain  is  very  acute,  and 
occurs  in  distinct  paroxysms,  gradually  increasing  in  severity,  until 
it  reaches  a  climax,  when  it  quickly  subsides.  The  attack  may 
occur  at  any  time  and  may  be  provoked  by  laughing,  talking,  the 
movement  of  a  muscle,  etc.;  even  a  slight  noise  or  Hght  touch, 
as  placing  the  hat  on  the  head,  may  cause  a  paroxysm.  The  patient 
lives  in  constant  dread  of  an  attack. 

There  is  no  condition  which  elicits  greater  sympathy  than  this, 
for  the  experienced  physician  or  surgeon  realizes  that  little  can  be 
done  either  medicinally  or  surgically.  Materia  medica  has  been 
exhausted  in  search  of  a  cure,  and  surgery  affords  only  temporary 
relief.  Patrick,  Moyer,  and  others  report  favorably  upon  the  use 
here  of  castor  oil.  The  drug  is  first  pushed  almost  to  catharsis,  then 
the  dose  is  decreased,  but  the  administration  of  the  drug  is  still 
kept  up.  Ultimately  the  patient  can  take  large  quantities  of  castor 
oil  without  the  cathartic  effect. 

Stekoulis,  Schapiro,  Bennett,  Murphy,  and  others  have  injected 
osmic  acid  into  the  substance  of  the  affected  nerve  and  report 
encouraging  results.  The  late  Dr.  J.  B.  Murphy,  however,  has 
directed  attention  to  the  great  tendency  of  nerve  tissue  to  regenerate; 
and  states  that  many  cases  of  tic  douloureux  will  recur,  even  when 
the  affected  nerve  has  been  severed  by  destroying  an  area  with  osmic 
acid  or  when  blocked  with  such  material  as  gutta-percha. 

Deep  injections  of  alcohol  in  the  region  of  the  orbit  of  the  affected 

^"Oral  Surgery,"  by  Dr.  Truman  W.  Brophy,  is  highly  recommended. 


452  PRACTICAL   DENTAL   THERAPEUTICS 

nerve  have  been  recently  suggested  for  the  rehef  of  facial  neuralgia. 
Patrick,  Moorehead,  Potts,  and  others  report  favorably  on  the 
method.  The  needle  generally  employed  is  one  adopted  by  Levy 
and  Bandonin,  which  is  graduated  in  centimeters  up  to  five.  The 
alcohol  should  be  about  75  per  cent.,  and  should  contain  a  very 
small  amount  of  cocain  hydrochlorid.  The  success  of  the  operation 
will  be  indicated  by  a  slight  anesthesia  over  the  parts  supplied  by  the 
nerve.  Upon  the  slightest  return  of  the  pain  the  operation  should 
be  repeated,  after  which  relief  for  some  months,  and  even  two  years 
or  more,  may  be  expected.  The  formula  used  by  Patrick  is  here 
given: 

I^ — Cocainse  hydrochloridi,  gr.  j  (0.064  Gm.) 

Chloroformi,  m.  x  (0.61  mil) 

Alcoholis,  fSiij  (12.0  mils) 

Aquae  distillatae,  q.  s.  ad.  f5ss  (15.0  mils) — M. 

Sig. — Use  as  directed  above. 

On  the  whole,  it  may  be  stated  that  the  therapeutics  of  tic  doulou- 
reux is  discouraging  to  all  concerned.  Hirt  sums  up  the  conditions 
very  properly  when  he  says:  "Numerous  are  the  means  at  our  com- 
mand for  combating  tic  douloureux,  and  quite  as  numerous  are  the 
patients  who,  after  hundreds  of  unsuccessful  trials,  have  given  up  in 
despair  all  medicines  and  all  physicians." 

The  condition  has  not  been  thus  briefly  discussed  here  because 
of  the  likelihood  of  dentists  being  called  upon  to  treat  it,  but  rather 
because  they  are  often  called  in  consultation  on  the  case  to  aid  in 
making  a  correct  diagnosis. 


DIAGNOSIS    AND    TREATMENT    OF   DISEASES    OF  THE 

SOFT   TISSUES   OF   THE   MOUTH   NOT    DIRECTLY 

ASSOCIATED  WITH  THE  TEETH 

GENERAL  CONSIDERATIONS 

In  this  general  group  will  be  considered  certain  diseases  of  the 
soft  tissues  of  the  mouth  other  than  those  directly  associated  with  the 
teeth,  The  etiology  and  pathology  of  these  diseases  will  be  consid- 
ered somewhat  more  fully  than  has  been  done  with  the  diseases  of 
the  hard  tissues  of  the  mouth  and  associated  structures,  for  the 
reason  that  dentists,  as  a  rule,  are  not  so  familiar  with  the  etiology 
and  pathology  of  the  diseases  under  consideration  here,  and,  therefore, 
find  it  more  difficult  to  differentiate  between  some  of  these  condi- 
tions and  to  make  a  correct  diagnosis — upon  which  the  successful 
therapeutics  is  based.  Our  profession  has  been  criticised  in  the 
past,  and,  perhaps,  in  a  measure  justly  so,  because  it  is  claimed  that 
in  our  examinations  of  the  mouth  we  have  been  looking  only  for 
cavities  in  the  teeth  and  have  not  noted,  at  the  same  time,  the  condi- 
tion of  the  oral  mucous  membrane  and  soft  tissues.  The  tendency 
is  to  broaden  our  perspective,  and  the  live  dentist  of  to-day  realizes 
the  importance  of  a  knowledge  of  the  pathology  of  the  soft  tissues  of 
the  mouth  as  well  as  of  the  teeth  themselves. 

The  mouth  is  a  hot-bed  for  many  kinds  of  bacteria,  and  is  there- 
fore a  fruitful  field  for  diseases  of  almost  every  description.  Some 
of  these  diseases  are  purely  local,  having  certain  definite  causes,  while 
others  are  local  manifestations  of  some  general  disorder.  Even 
those  diseases  that  are  caused  by  local  infections  are  influenced  in 
most  instances  by  the  condition  of  the  stomach  or  general  metabolism 
of  the  individual.  The  mouth  and  the  stomach  are  intimately  con- 
nected and  closely  related ;  so  much  so  in  fact  that  pathologic  condi- 
tions in  the  one  often  predispose  to  disease  in  the  other.  We  can 
more  readily  understand  the  close  relation  that  exists  between  dis- 
eases of  these  two  organs  when  we  remember  that  much  of  the  septic 
material  of  the  mouth  ultimately  finds  its  way  to  the  stomach  and 
intestines,  and  the  toxins  absorbed  from  the  digestive  tract  are  fre- 
quently excreted  in  the  saliva.  Michaels  claimed  the  saliva  to  be 
pathognomonic  of  certain  systemic  diseases,  the  diagnosis  being 
made  by  him  solely  by  physical  and  chemic  examinations  of  the 
saliva. 

453 


454  PRACTICAL   DENTAL   THERAPEUTICS 

Some  of  the  diseases  of  the  mouth  are  characteristic  and  easily 
differentiated  and  diagnosed;  while  the  correct  inteipretation  of  the 
clinical  manifestations  of  others  is  exceedingly  difficult  and  often- 
times baffles  the  most  skillful  diagnostician.  In  our  larger  cities  we 
are  fortunate  in  having  the  pathologic  laboratories  which  must  fre- 
quently be  used  in  order  to  confirm  our  clinical  diagnosis. 

CANKER  SORES 

Canker  sores  are  true  ulcers  and  are  among  the  more  common 
pathologic  conditions  of  the  soft  tissues  of  the  mouth.  They  are  sup- 
posed to  have  their  origin  primarily  in  the  mouth,  yet  Pusey  and 
others  believe  them  to  arise  from  trophic  disturbances.  The  author 
has  observed  that  women  are  peculiarly  susceptible  to  this  condition 
during  the  menstrual  period.  Some  women  have  canker  sores 
nearly  every  time  they  menstruate.  They  seem  to  be  associated 
also  with  gastrointestinal  distrubances.  They  always  appear  sud- 
denly and  are  very  persistent  unless  given  suitable  treatment. 

Diagnosis. — Gilmer^  states  that  "they  most  commonly  occur  at 
the  duplicature  of  the  mucosa  of  the  cheek  and  the  gums,  though  they 
are  occasionally  seen  on  the  floor  of  the  mouth  and  on  the  edges  and 
under  the  surfaces  of  the  tongue.  They  vary  in  size  from  that  of  a 
grain  of  wheat  to  that  of  a  small-sized  bean.  Their  depth  varies, 
but  they  can  never  be  considered  superficial.  Their  margins  are 
rather  well-defined,  but  not  so  markedly  as  are  chancrous  ulcers  of 
similar  tissues,  neither  are  they  so  irregular  as  lupous  ulcers  of 
the  mouth.  The  mucosa  for  a  quarter-  to  a  half-inch  from  the  ulcer 
is  a  deep  red  color.  The  base  of  the  ulcer  is  overlaid  with  a  grayish- 
white  necrotic  covering,  not  unlike  that  found  in  syphiHtic  ulcers  in 
the  mouth.  When  this  coating  is  removed,  a  granulating  surface  is 
exposed,  which,  while  extremely  sensitive  to  the  touch,  bleeds  but 
slightly,  if  at  all.  These  ulcers  are  so  distinctive  in  their  appearance 
that  they  can  hardly  be  mistaken  for  any  other  lesion." 

Therapeutics. — The  treatment  of  canker  sores  is  purely  local,  and 
the  sooner  it  is  instituted  the  less  persistent  the  ulcer  will  be.  The 
necrotic  tissue  may  be  carefully  removed  by  scraping,  or  cleansed 
with  hydrogen  dioxid,  after  which  the  raw  surface  should  be  dried 
and  cauterized.  They  generally  yield  nicely  to  one  application  of 
silver  nitrate.  For  this  purpose  a  lo  per  cent,  solution  may  be  used; 
a  20  per  cent,  solution  of  argyrol  may  also  be  employed.  The  ulcer 
being  acutely  sensitive,  it  is  sometimes  better  to  use  95  per  cent. 

1  Dental  Review,  Vol.  XXIII,  p.  496. 


DISEASES    OF    THE    SOFT   TISSUES    OF   THE   MOUTH  455 

phenol  as  the  cauterizing  agent.  The  analgesic  effect  thus  produced 
is  often  of  value.  The  mouth  should  be  kept  clean,  when  the  ulcers 
usually  heal  without  further  treatment. 

HERPES  LABIALIS 

Herpes  labiaKs,  also  called  cold  sores  or  fever  sores,  have  a  similar 
origin  to  canker  sores.  They  are  of  a  herpetic  nature,  and  differ  in 
appearance  from  the  latter  principally  on  account  of  the  location  and 
tissues  involved.  Of  these  Gilmer  says:  "Herpes  of  the  lips  (herpes 
labialis)  and  occasionally  of  the  gums  (herpes  gingivalis)  sometimes 
follow  dental  operations  and  cause  uneasiness  on  the  part  of  patient, 
who  often  attributes  this  condition  to  infection  from  unclean  arma- 
mentarium used  by  the  dentist,  when,  in  truth,  the  patient  is  of  a 
herpetic  diathesis,  and  under  such  circumstances  a  slight  irritation 
only,  in  such  locations,  being  sufficient  to  excite  the  condition." 

Diagnosis. — The  diagnosis  of  cold  sores  is  a  simple  matter. 
They  occur  frequently  when  the  patient  is  suffering  from  colds  or 
during  convalescence  from  fevers,  hence  the  name.  The  tissues 
immediately  around  the  area  involved  are  swollen  and  tender;  the 
membrane  is  dry  and  has  a  tendency  to  crack  and  bleeds  readily. 

Therapeutics. — The  treatment  of  cold  sores  consists  in  cleaning 
the  part  with  such  agents  as  hydrogen  dioxid  or  alcohol,  then  drying 
and  making  an  application  of  oil  of  cloves  or  spirit  of  camphor. 
Either  of  these  latter  agents  is  just  sufficiently  irritating  to  produce 
stimulation  of  the  cells  and  promote  healing.  If  the  cold  sore  is 
large  and  liable  to  crack  and  bleed  on  moving  the  lips,  it  can  be 
kept  soft  and  pliable  by  frequently  applying  euroform  paste,  or 
may  be  immobilized  by  applying  collodion.  In  the  latter  instance 
the  part  should  be  dusted  with  boric  acid  before  coating  with 
collodion. 

SYPHILIS 

S3rphilis  is  a  chronic  infectious  disease  now  known  to  be  produced 
by  a  specific  microorganism,  the  spirocheta  pallida — a  germ  discovered 
March  3,  1905,  by  Schaudinn  and  Hoffmann.  This  disease  is  much 
more  common  than  is  generally  supposed,  and  it  is  essential  that 
every  practising  dentist  be  famihar  with  its  characteristic  symptoms. 
Skill  in  the  diagnosis  of  syphiHtic  manifestations  is  of  the  utmost 
importance,  not  only  for  the  protection  of  the  dentist  himself,  but 
for  the  protection  of  his  patients  as  well.  Whenever  the  skin  on  the 
hand  or  finger  of  the  dentist  is  broken,  or  the  mucous  membrane  of 
the  patient's  lip,  gum,  or  cheek  is  punctured  by  an  instrument,  the 


456  PRACTICAL   DENTAL   THERAPEUTICS 

part  should  be  immediately  cauterized.  It  matters  not  whether  the 
dentist  ever  expects  to  treat  a  case  of  syphilis,  or  not,  the  menace  of 
the  presence  of  this  disease  can  only  be  avoided  by  the  careful  and 
intelligent  reading  of  the  clinical  symptoms. 

Acquired  extragenital  syphihs  is  primarily  manifested  in  and 
about  the  soft  tissues  of  the  mouth  in  what  is  known  as  the  initial 
lesion  or  hard  chancre,  which,  as  a  rule,  develops  in  from  three  to  six 
weeks  after  infection.  The  chancre  may  occur  in  various  locations 
— on  the  lips,  tips  of  the  tongue,  and  the  pharynx — and  is  character- 
istic of  what  is  known  as  primary  symptoms. 

Primary  Syphilis. — The  infection  here  is  produced  by  direct  con- 
tact of  the  spirocheta  pallida  with  an  abraded  surface.  According  to 
Logan, ^  the  principal  means  of  conveying  the  infection  extragenitally 
is  through  the  act  of  kissing,  drinking  from  a  broken  utensil,  the 
use  of  a  pipe  or  handkerchief  that  has  been  contaminated  with  the 
germ,  or  from  physicians'  or  dentists'  instruments  or  fingers  that 
have  had  the  infected  secretions  from  the  mouth  of  a  previous  patient 
dried  upon  them. 

Diagnosis. — In  the  locations  found  in  the  mouth,  chancre  is 
usually  single,  though  it  may  be  multiple  (Fig.  141).  It  may  appear 
first  as  a  papule,  the  superficial  cells  of  which  finally  ulcerate,  with 
necrosis  of  the  central  area  quickly  following,  when  a  copious  and 
highly  infectious  discharge  comes  from  the  crater-like  opening  that  is 
forming  on  the  tissues  involved.  The  ulceration  occurs  in  from 
four  to  ten  days  after  full  development  of  the  chancre,  until  which 
time  the  patient,  as  a  rule,  experiences  very  little  pain  or  discomfort. 

Therapeutics. — The  treatment  of  the  primary  symptoms,  until 
recent  years,  was  considered  unimportant.  In  fact,  unless  a  positive 
diagnosis  could  be  made,  and  it  is  still  often  difficult  to  be  certain  of 
the  cHnical  diagnosis  at  this  stage  of  the  disease,  it  was  suggested  that 
the  treatment  be  deferred  until  the  diagnosis  was  established  by  the 
manifestations  of  the  secondary  symptoms.  This  has  been  changed. 
Ehrlich,  the  discoverer  of  salvarsan — or  "606,"  as  it  is  commonly 
called — the  new  specific  for  syphilis,  says,  "too  much  weight  can- 
not be  laid  upon  the  importance  of  diagnosing  a  syphilitic  sore  as 
soon  as  possible.  We  should  certainly  not  wait  for  secondaries  to 
develop  or  until  the  Wassermann  reaction  has  become  positive. 
In  no  period  of  syphilis  is  salvarsan  more  strongly  indicated  than 
when  the  chancre  is  the  sole  symptom."  S3^hilis  is  now  known 
to  be  a  germ  disease,  and  the  only  positive  means  of  confirming  the 
diagnosis  of  the  clinical  symptoms  in  this  stage  is  the  microscope  by 

^Denial  Review,  Vol.  XXII,  p.  800. 


Fig.  141. — Chancres  of  the  lower  lip,  and  mucous  patches  of  the  tongue.  The 
disease  was  contracted  by  kissing,  a,  Chancres;  b,  mucous  patches.  {Brophy,  after 
Zinsser-Stein.) 


DISEASES    OF    THE    SOFT   TISSUES    OF    THE   MOUTH  457 

which  the  spirocheia  pallida  may  be  discovered.  These  appear  as  fine, 
closely  coiled  spirals,  6  to  15  microns  long,  and  feebly  motile.  They 
are  most  abundant  in  the  margins  of  the  lesions,  and  are  practically 
constant  in  chancre  and  mucous  patches.  Old  chancres  and  those 
treated  by  local  antiseptics  may  easily  fail  to  show  the  organisms 
(White  and  Martin). 

The  technic  of  injecting  salvarsan  or  neosalvarsan  will  not  be 
described  here,  for  the  author  believes  it  to  be  the  duty  of  the  dentist, 
as  soon  as  he  observes  the  suspicious  sore  in  the  mouth,  to  consult 
with  the  family  physician,  who  should  inaugurate  and  follow  up  the 
specific  treatment.     Oral  hygiene,  of  course,  should  not  be  neglected. 

For  a  great  many  years  mercury  has  been  the  only  specific  for 
syphilis,  except  in  the  tertiary  stage  when  potassium  iodid  is  indi- 
cated. But,  unfortunately,  mercury  in  its  curative  dose  is  extremely 
poisonous,  so  that  small  doses  must  be  used  for  a  long  period  of 
time.  Because  of  this  disadvantage  many  attempts  have  been  made 
to  discover  a  mercurial  compound  which  would  fulfil  the  ideal  thera- 
peutic requirement;  viz.,  to  kill  the  spirochetae  by  means  of  a  single 
injection.  The  nearest  approach  to  this  was  the  discovery  of  atoxy- 
late  of  mercury  by  Uhlenhuth  and  Manteufel.  By  using  this  drug 
they  were  able  with  four  injections  to  kill  all  of  the  spirochetae  which 
were  produced  by  local  inoculation  of  the  testicles  in  rabbits. 
Not  only  were  four  injections  insufficient  to  have  a  like  effect  in  man, 
but  the  doses  required  were  much  larger  comparatively,  and,  as  a 
result,  toxic  symptoms  developed  and  recurrences  were  frequent; 
so  atoxylate  of  mercury  was  never  extensively  employed.  The  dis- 
covery of  this  product,  however,  acted  as  a  stimulus  and  spurred 
chemists  on  to  further  investigation. 

It  may  seem  strange  to  those  who  are  more  or  less  familiar  with 
the  drugs  that  have  been  employed  in  the  treatment  of  syphilis 
that  the  latest  specific  for  the  disease  is  a  compound  of  arsenic  and 
not  of  mercury.  The  formula  for  '606'  is  C12H12N2O2AS2.  Ehrlich 
claims  that  his  discovery  was  due  largely  to  the  well-known  fact  that 
the  compounds  of  arsenic  exerted  a  far  greater  influence  in  sleeping 
sickness  than  did  the  compound  of  mercury,  and  it  was  for  this 
disease  that  atoxyl  was  discovered.  When  it  was  shown,  in  1905, 
that  s3q)hiHs  was  caused  by  the  spirocheta  palHda,  a  protozoon  which 
doubtless  belonged  to  the  same  group  as  the  germ  which  produces 
sleeping  sickness  (trypanosomes) ;  and  since  arsenic  had  often  played 
an  important  role  in  the  treatment  of  syphihs,  the  later  synthetic 
compounds  discovered,  of  which  atoxyl  was  the  stimulus,  came  to 
be  used  for  syphihs  as  well  as  for  sleeping  sickness. 


458  PRACTICAL   DENTAL   THERAPEUTICS 

Secondary  Syphilis. — The  manifestations  of  what  is  known  as  the 
secondary  symptoms  do  not  appear  until  from  four  to  six  weeks 
after  the  development  of  the  hard  chancre. 

Diagnosis. — If  no  treatment  has  been  instituted,  eruptions  on 
the  skin  usually  mark  the  beginning  of  this  stage,  and,  according  to 
L.  Blake  Baldwin,  eruptions  are  frequently  found  on  the  oral  mucous 
membrane  quite  similar  to  those  upon  the  skin.  These  eruptions 
are  accompanied  by  fever,  sometimes  preceded  by  it.  Simultaneously 
with  the  eruptions  and  fever  characteristic  mucous  patches  occur, 
and  may  be  located  on  any  part  of  the  mucosa  of  the  mouth,  regard- 
less of  whether  the  disease  originated  primarily  or  secondarily  in 
the  mouth.  (Fig.  141,  h,  and  Fig.  142,  a,  b,  and  c.)  The  presence 
of  mucous  patches  is  a  positive  sign  of  syphiHs.  They  differ  from 
canker  sores  in  that  they  have  more  clearly  defined  margins  and 
are  not  so  painful  to  the  touch,  and  the  immediate  area  is  not  of 
such  a  deep  red  color  (Gilmer).  The  mucous  patches  are  exceedingly 
infectious,  and  due  caution  should  be  observed  not  to  carry  the 
infection  from  one  patient  to  another. 

Therapeutics. — Inasmuch  as  secondary  syphilis  is  manifested  in 
the  mouth  and  leaves  its  indelible  effects  upon  the  gums,  jaws,  and 
adjacent  structures,  mercury  is  the  one  drug  indicated  in  its  treat- 
ment, for  this  drug  has  a  selective  influence  upon  these  structures. 
In  fact,  mercury  is  a  specific  for  the  secondary  symptoms,  though  its 
action,  as  yet,  rests  purely  upon  an  empirical  basis.  It  is  not  even 
known  whether  the  action  of  the  drug  here  is  due  to  specific  toxicity 
for  the  spirocheta  pallida  or  whether  it  is  simply  due  to  its  general 
effects  upon  metabolism.  The  former,  according  to  Sollmann, 
seems  to  be  the  case.  Mercury  is  not  only  palHative,  but  curative 
in  this  stage — congenital  as  well  as  acquired — whilst  its  administra- 
tion is  worse  than  useless  in  the  first  and  third  stages. 

The  systemic  treatment,  of  course,  should  be  relegated  to  the 
family  physician.  Long^  very  properly  emphasizes  a  word  of  cau- 
tion here.  He  says:  "It  may  fall  to  the  dentist  to  discover  a  case 
of  syphilis,  by  mouth  symptoms,  where  it  had  not  been  suspected, 
but  he  must  be  exceedingly  cautious  about  discussing  this  finding 
with  the  patient.  He  is  dealing  with  a  matter  for  which  he  has  not 
been  consulted,  and  in  any  suspicious  acts  or  words  of  his  lie  the 
possibilities  of  much  unpleasantness.  If  the  patient  be  an  innocent 
wife,  a  statement  of  his  discovery  might  produce  domestic  discord. 
While  she  would  have  a  most  serious  grievance,  entitling  her  to  our 
pity,  a  revelation  could  only  add  to  her  unhappiness.     A  suggestion 

^  Dental  Materia  Medica  and  Therapeutics,  p.  206. 


a 


Fig.  142. — Syphilitic  mucous  patches  of  the  lips.  The  lips  are  swollen,  a,  Ulcerated 
mucous  patch.  On  the  base  of  the  ulcer  is  a  yellow  coating  with  dried  secretions  about 
its  borders,  h.  Ulcerations  which  are  not  as  far  advanced  as  a.  c,  Mucous  patch. 
{Brophy,  after  Zinnser-Stein.) 


DISEASES    OF   THE    SOFT   TISSUES    OE    THE    MOUTH  459 

to  her  to  see  her  family  physician  for  certain  general  conditions  that 
you  find  evidence  of,  would  be  the  proper  course;  and  even  this 
advice  must  be  given  tactfully,  without  arousing  suspicion  as  to  the 
probabilities  in  the  case,  for,  after  all,  a  mistaken  diagnosis  is 
possible." 

The  preparations  of  mercury  most  frequently  prescribed  in 
syphilis  are  mercury  with  chalk,  and  compounds  like  bichlorid, 
biniodid,  and  protiodid.  The  ointments  are  used  by  inunction. 
None  of  these  preparations  should  be  pushed  to  the  extent  of 
producing  ptyalism  or  salivation. 

An  accurate  and  positive  diagnosis  of  syphilis  should  always  be 
made  before  instituting  the  mercurial  treatment,  otherwise  disastrous 
results  are  almost  certain  to  follow.  In  a  recent  case  of  a  little  girl, 
seven  years  old,  of  doubtful  syphiHtic  history,  coming  under  the 
observation  of  the  author,  a  sequestrum  was  removed  which  con- 
tained the  erupted  first  permanent  molar  and  the  crowns  of  the  non- 
erupted  first  and  second  bicuspids.     The  case  terminated  fatally. 

Syphilographers  have  learned  from  sad  experience  that  mercury 
can  be  pushed  much  farther  without  producing  ptyalism,  if  the 
mouth  has  first  received  a  thorough  prophylactic  treatment.  This 
includes  the  removal  of  all  local  irritants,  such  as  hard  and  soft 
deposits,  overhanging  fillings,  ill-fitting  crowns,  and  bridges.  In 
fact,  it  is  only  when  the  mouth  and  teeth  are  clean  that  the  symp- 
toms of  ptyalism  are  valuable  as  an  index  that  the  system  is  taking 
all  the  mercury  it  can  absorb  without  producing  marked  toxic  effects. 
If  the  teeth  are  not  clean  and  the  mucous  membrane  healthy,  it  is 
best  to  wait  until  the  mouth  receives  proper  attention  before  attempt- 
ing to  find  the  minimum  toxic  dose  of  the  drug.  On  this  point,  White 
and  Martin^  state  that  "the  teeth  should  be  put  in  perfect  order 
by  a  competent  dentist,  and  should  be  kept  scrupulously  clean 
throughout  the  entire  course  of  treatment  by  cleansing  washes, 
astringent  and  mildly  antiseptic  powders  (or  pastes),  and  careful 
removal  of  particles  of  food  by  means  of  tooth-picks  and  dental 
floss  immediately  after  eating.  Upon  the  health  of  the  mucous  mem- 
brane of  the  mouth  depends,  to  a  great  extent,  the  abihty  of  the 
patient  to  take  an  efficient  quantity  of  mercury  without  causing 
salivation." 

Dentists  in  the  past  have  hesitated  to  work  for  patients  who 
were  known  to  have  the  specific  disease  on  account  of  the  danger 
of   self-infection,   and   the  subsequent  necessity  of   discarding   all 

^  Genito-Urinary  and  Venereal  Diseases,  Ninth  Edition,  p.  1008. 


460  PRACTICAL   DENTAL    THERAPEUTICS 

instruments  used.  Logan^  says:  "These  syphilitic  individuals  can 
be  cared  for  with  impunity  if  the  operator  protects  his  hands  with 
rubber  gloves  and  then  scrubs  all  the  instruments  employed  and  boils 
them  for  fifteen  minutes.  If  this  plan  is  pursued,  there  is  no  need 
of  such  absurd  action  as  is  often  recommended — that  all  such 
instruments  should  never  be  used  again,  but  thrown  away." 

Tertiary  Sjrphilis. — This  condition  may  be  prevented  if  proper 
treatment  has  been  previously  inaugurated.  In  cases  not  so  treated 
the  tertiary  symptoms  usually  occur  in  from  one-half  to  two  years 
after  infection. 

Diagnosis. — Gummata  mark  the  third  stage  of  syphilis  and  first 
appear  as  hard  bodies  or  nodes  occurring  mostly  under  the  skin, 
although  they  may  form  under  the  mucosa  of  the  mouth.  They 
gradually  increase  in  size,  and  become  more  superficial,  with  a  tend- 
ency to  break  down  and  ulcerate.  (Fig.  143,  a.)  When  they  occur 
in  the  region  of  the  hard  palate,  the  underlying  bone  frequently 
becomes  involved  and  extensive  necrosis  of  the  palate  and  nasal 
bones  follows.  (Fig.  144.)  Gilmer^  states  that  subperiosteal 
gummata  are  especially  destructive  to  bone,  and  reports  having  seen 
cases  in  which  the  soft  palate  also  was  completely  destroyed  from 
ulceration  of  gummata  in  that  locality.  Authorities  differ  in  regard 
to  whether  the  lesions  of  tertiary  syphiHs  are  infectious.  They  are 
probably  but  slightly  so,  if  at  all;  however,  it  is  well  here  also  to 
guard  against  spreading  possible  infection. 

Therapeutics. — The  one  drug  indicated  in  the  treatment  of 
tertiary  sj^hilis  is  the  great  alterative,  potassium  iodid.  In  this 
stage  of  the  disease  the  efficacy  of  potassium  iodid  is  equal  to  that 
of  mercury  in  the  secondary  stage,  and  it  may  be  considered  a  specific. 
The  systemic  treatment  should  be  relegated  again  to  the  family 
physician.  The  initial  dose  of  the  drug  should  be  small,  and  the 
amount  gradually  increased  until  improvement  follows  or  symptoms 
of  iodism  appear.  For  permanent  results  it  is  necessary  to  continue 
the  antisyphilitic  treatment  for  from  six  months  to  a  year  or  more. 

The  question  of  whether  syphilis  can  be  cured  or  not  has  been  a 
debatable  one  in  the  past,  but  its  cure  is  no  longer  questioned  by 
experienced  syphilographers.  Yet  it  may  be  safely  stated  that  few 
cases  are  ever  permanently  cured,  for  only  a  small  percentage  of 
patients  will  continue  the  treatment  sufficiently  long,  after  they  feel 
perfectly  weU,  to  effect  a  permanent  cure. 

It  should  be  remembered  that  syphilis  stamps  its  indelible  effects 

1  Dental  Review,  Vol.  XXII,  p.  813. 
*  Dental  Review,  Vol.  XXIII,  p.  4g8. 


h 

Fig.  143. — Ulcerated  gummata  of  the  hard  palate  mucous  membrane,  a,  Grayish- 
yellow  deposits  upon  the  ulcerated  surface;  h.  highly  congested  mucous  membrane. 
{Brophy,  after  Zinsser-Stein.) 


h 


Fig.  144. — Perforated  hard  palate.  Perforation  of  the  hard  palate  due  to  gummata 
with  general  periosteitis  of  the  alveolar  processes,  a,  Hole  left  in  the  palate  by  the  de- 
struction of  the  bone  and  soft  parts;  h,  destruction  of  the  alveolar  processes  and  perfor- 
ation into  the  nose;  c,  change  of  position  of  the  teeth.     {Brophy,  after  Zinsser-Stein^ 


DISEASES    OF   THE    SOFT   TISSUES    OF    THE    MOUTH  46 1 

upon  the  individual  thus  afflicted  in  almost  every  case,  and  that  any 
subsequent  infection,  like  that  in  alveolar  abscess  or  pyorrhea  alveo- 
laris,  is  likely  to  extensively  involve  the  osseous  structures,  and  yield 
to  the  ordinary  treatment  with  difficulty.  The  author  has  previously 
referred  to  a  case  of  extensive  necrosis  following  sUght  trauma  after 
the  removal  of  a  pulp  by  pressure  anesthesia,  where  every  due  pre- 
caution was  taken  to  maintain  asepsis  in  performing  the  operation 
(see  Fig.  6i,  p.  378). 

In  conclusion  I  desire  here  again  to  emphasize  the  fact  that  every 
dentist  should  so  school  himself  in  this  dreadful  disease  that  he  may 
be  able  to  at  once  recognize  its  various  manifestations.  When  in 
doubt  about  a  lesion  in  the  mouth,  it  is  always  better  for  dentists 
to  assume  that  it  is  specific  in  character,  and  take  every  due  precaution 
against  infecting  themselves  or  their  patients. 

MERCURIAL  STOMATITIS 

Mercurial  stomatitis  is  a  condition  of  the  mouth  frequently  fol- 
lowing the  administration  of  mercury  and  its  compounds  for  the 
treatment  of  syphilis  and  other  conditions.  The  drug  is  used  for 
its  alterative  and  tonic  effects.  As  has  been  mentioned,  it  is  a  specific 
for  secondary  syphiHs,  and  every  dentist  should  be  thoroughly 
familiar  with  the  effects  of  this  metal  when  taken  internally. 

Diagnosis. — When  small  doses  of  an  unirritating  preparation  of 
the  drug  are  given  continuously  for  a  certain  length  of  time,  the  first 
effects  are  observed  in  the  mouth,  for  it  has  a  selective  influence 
upon  the  gums,  jaws,  and  adjacent  structures.  There  is  produced 
an  increased  flow  of  saHva,  fetor  of  the  breath,  redness  of  the  gum 
margins,  and  pericementitis,  causing  soreness  of  the  teeth  when 
the  jaws  are  forcibly  brought  together.  If  the  drug  is  not  withdrawn 
upon  the  appearance  of  these  symptoms,  the  condition  gradually 
grows  worse;  salivation  becomes  excessive  (continual  droohng), 
the  gums  become  swollen  and  spongy,  the  teeth  loosen  from  their 
sockets  and  may  be  easily  extracted  with  the  fingers,  the  tongue 
and  parotid  glands  enlarge — the  former  sometimes  to  the  extent  that 
it  protrudes  from  the  mouth;  often  there  are  deep  sloughing  ulcers 
made  by  indentations  of  the  teeth  upon  its  edges,  also  upon  the 
mucous  membrane  of  the  cheeks;  and,  finally,  the  soft  tissues  around 
the  teeth  slough  away,  necrosis  of  the  bones  sets  in,  and  large  sequestra 
form.  This  group  of  symptoms  is  known  "as  ptyalism  or  salivation. 
In  these  cases  the  general  health  is  naturally  affected,  the  patient 
becomes  pale  and  loses  flesh.     Chronic  mercurial  poisoning  occurs 


462  PRACTICAL  DENTAL   THERAPEUTICS 

frequently  in  workmen  who  handle  the  metal  or  who  are  exposed  to 
its  fumes,  such  as  makers  of  thermometers,  mirrors,  scientific  instru- 
ments, etc.  The  condition,  however,  is  too  frequently  produced 
by  the  prolonged  use  of  mercury  as  a  medicine. 

Therapeutics. — The  treatment  of  mercurial  stomatitis  has  been 
fully  considered  under  Mercury  (see  p.  194). 

TUBERCULOSIS 

Tuberculosis  is  known  as  the  "great  white  plague."  The  disease 
is  caused  by  the  tubercle  bacillus.  Brophy^  says:  "The  tubercle 
bacillus  may  enter  the  body  by  several  avenues.  The  inhalation 
method  is  the  one  most  commonly  met  with.  The  sputum  of  con- 
sumptives contains  vast  numbers  of  the  bacilli  and  the  atmosphere 
immediately  surrounding  these  patients,  as  well  as  the  dust,  is  very 
infective.  Those  who  contract  tuberculosis  by  this  method  usually 
develop  the  pulmonary  form  of  the  disease  or  the  bronchial  glands 
become  the  seat  of  infection  and  other  organs  are  involved  from 
these.  The  tonsils  also  may  be  the  seat  of  the  primary  lesion,  as 
the  crypts  offer  an  excellent  place  for  the  growth  of  the  tubercle 
bacillus.  The  glands  of  the  neck  may  become  secondarily  involved, 
following  infection  of  the  tonsil."  In  this  connection  it  may  be 
remembered  that  Cook,  Moorehead,  and  others  have  reported  cases 
where  the  bacilli  have  entered  the  system  through  the  canals  of 
pulpless  teeth  and  pyorrheal  pockets,  involving  the  glands  in  the 
neighboring  region. 

The  disease  is  occasionally  seen  on  the  mucosa  of  the  mouth. 
Gilmer^  reports  having  seen  three  cases,  one  of  the  tongue,  one  of  the 
sublingual  salivary  gland,  and  one  an  extensive  involvement,  includ- 
ing a  part  of  the  lips,  the  mucosa  of  the  cheek,  the  soft  palate,  the 
tongue,  and  a  portion  of  the  pharynx. 

Diagnosis. — The  microscope  will  aid  in  definitely  determining 
tubercular  lesions  in  the  mouth,  as  well  as  in  other  parts  of  the  body 
(Fig.  145).  The  tubercle  is  the  characteristic  lesion  produced  by  the 
bacillus.  It  will  be  noticed  that  the  ulcers  arise  from  the  confluence 
of  numerous  miliary  tubercles.  The  ulcers  are  usually  covered 
with  yellowish- white  pus. 

Therapeutics. — The  dentist  may  first  discover  the  lesion  and 
aid  in  making  the  diagnosis;  but  treatment  had  better  be  given  by 
the  general  medical  practitioner  or  specialist,  for  the  cases  are  rare 

*  Oral  Surgery,  p.  67. 

2  Dental  Review,  Vol.  XXIII,  p.  499. 


Fig.  145. — Tuberculosis  of  the  upper  lip  and  gum,  shomng  the  tubercles.     {Brophy, 
after  Royal  College  of  Surgeons.) 


Fig.  146. — Leucoplakia  of  the  tongue  of  many  years'  duration,  in  a  male  of  50  years, 
with  one  slightly  raised  firm  spot,  where  a  small  innocent  wart  had  been  cut  out  a 
3^ear  before.  This  spot  was  not  excoriated  or  raw  and  could  only  be  distinguished  from 
the  surrounding  white  patches  by  its  slight  induration,  which  was  quite  superficial. 
Examined  by  the  Imperial  Cancer  Research,  and  found  to  be  a  small  but  typical 
squamous-celled  carcinoma.     {Brophy,  after  Builin.) 


DISEASES    OF   THE    SOFT   TISSUES    OF    THE   MOUTH  463 

and  no  definite  local  treatment  has  thus  far  been  permanently 
established.  It  may  be  stated,  however,  that  various  forms  of  light 
have  been  used  in  many  cases  with  favorable  results  in  tubercular 
and  similar  affections.  Where  there  is  bone  involvement  Beck 
reports  surprising  results  from  the  injection  of  bismuth  paste. 

LEUCOPLAKIA  BUCCALIS 

Leucoplakia  is  a  disease  of  the  mouth  and  tongue,  the  etiology  of 
which  is  as  yet  unknown.  A  large  percentage  of  the  cases  of  leuco- 
plakia buccalis  give  a  previous  history  of  syphilis.  It  is,  therefore, 
suspected  that  the  latter  disease  has  a  causative  relation  to  leuco- 
plakia, though  no  definite  evidence  in  this  respect  has  been  produced. 
Gilmer,^  who  has  seen  a  large  number  of  cases,  is  of  this  opinion. 
He  says:  "Many  cases  of  leucoplakia  buccalis  have  come  under  my 
observation,  and,  with  few  exceptions,  I  was  able  to  ehcit  a  history 
of  syphilis." 

Diagnosis. — The  disease  manifests  itself  upon  the  buccal  mucosa, 
portions  of  the  gums  and  the  dorsum  and  edges  of  the  tongue,  and 
other  places.  There  appear,  sharply  outlined,  whitish  or  silver- 
colored  points,  streaks,  bands,  or  patches  of  irregular  shape,  either 
flattened  or  slightly  elevated  above  the  level  of  the  general  mucosa. 
Ordinarily  they  simply  present  a  roughened  surface  without  much 
discomfort.  They  occur  almost  exclusively  in  the  mouths  of  men 
who  are  excessive  smokers.  The  condition,  however,  should  not  be 
mistaken  for  that  which  is  frequently  seen  in  the  mouth  of  excessive 
smokers,  especially  pipe  smokers,  where  there  is  a  whitening  of  exten- 
sive areas  of  the  tongue  or  hard  palate  or  both.  Gilmer^  says: 
"  The  epithehum  of  the  smoker's  tongue  is  of  a  brownish-white,  while 
in  leucoplakia  the  patches  are  of  a  clear  white  color."  Leucoplakia 
patches  are  very  characteristic,  no  other  condition  of  the  mouth 
presents  the  same  cHnical  picture.  The  alTection  is  painless,  and 
may  be  overlooked  by  the  patient  unless  it  becomes  complicated 
with  cancer  (See  Fig.  146). 

Therapeutics.- — It  has  been  observed  that  carcinoma  frequently 
has  its  beginning  in  the  site  of  an  old  leucoplakia  patch.  Since  this 
is  true,  an  early  diagnosis  should  be  made,  and  the  proper  treatment 
instituted  by  the  family  physician.  In  cases  of  known  syphilis  the 
antisyphilitic  treatment  would  be  indicated.  The  general  tendency 
of  dentists  in  conditions  of  this  kind  is  to  use  cauterants,  such  as 

^  Dental  Review,  Vol   XXIII,  p.  500. 
^Ibid. 


464  PRACTICAL   DENTAL   THERAPEUTICS 

silver  nitrate.     In  the  treatment  of  leucoplakia  this  should  be  avoided, 
as  it  only  tends  to  aggravate  the  disease. 

ACTINOMYCOSIS 

Actinomycosis  is  a  common  disease  among  the  lower  animals, 
especially  cattle,  and  is  known  as  lumpy -jaw,  the  disease  affecting 
the  lower  jaw  and  cervical  glands.  Cases  in  the  human  being  have 
been  reported  by  Brophy,  Bevan,  Zederbaum,  and  others.  It  is 
produced  by  the  ray-fungus,  which  is  normally  found  in  grain,  and  is 
supposed  to  find  its  way  into  the  mouth  from  the  habit  of  chewing 
straws.  The  germs  gain  admittance  into  the  tissues  from  the  mouth 
through  decayed  teeth. 

Diagnosis. — The  microscope  affords  a  positive  means  of  diag- 
nosis. Blair  states^  that  "the  disease  first  manifests  itself  in  the 
form  of  a  small  nodule,  which  for  a  time  may  give  no  trouble,  but 
later  softens  and  forms  sinuses  from  which  is  discharged  a  thin 
fluid  which  usually  contains  the  fungus." 

Therapeutics.- — The  treatment  of  the  disease  had  better  be  car- 
ried on  by  the  medical  speciaHst,  as  it  is  so  rare  in  the  human  being 
that  dentists  but  seldom  see  the  condition.  Based  on  observations 
made  at  the  Wisconsin  Experimental  Agricultural  Station,  Bevan 
introduced  the  copper  sulphate  treatment  in  man,  and  both  he  and 
Brophy  report  good  results  by  using  the  drug  to  the  limit  of  tolera- 
tion. They  begin  with  about  3^^  gr.  given  three  times  a  day, 
gradually  increasing  the  dose  to  i  gr.  In  addition  to  the  inter- 
nal administration  of  copper  sulphate,  irrigations  of  a  i  per  cent, 
solution  are  also  employed. 

ACUTE  ULCEROUS  GINGIVITIS 

Acute  ulcerous  gingivitis  is  a  comparatively  rare  disease.  The 
author,  however,  has  seen  a  number  of  cases  in  the  mouths  of  children 
coming  to  the  College  Infirmary  for  treatment  from  the  so-called 
"slum  districts "  of  Chicago.  This  may  have  been  a  coincidence,  but 
I  have  never  observed  the  typical  disease  in  well-kept  mouths.  It 
may  be  regarded  as  a  filth  disease. 

Diagnosis. — Gilmer^  well  describes  the  disease  as  follows:  "It 
attacks  simultaneously  the  gum  margins  on  their  buccal  or  labial 
aspect  about  two,  three,  or  possibly  four  teeth,  at  the  same  time. 

^  Surgery  and  Diseases  of  the  Mouth  and  Jaws,  p   304 
•    ^Dental  Review,  Vol.  XXIII,  p.  501. 


DISEASES    OF   THE    SOFT   TISSUES    OF   THE   MOUTH  465 

The  ulcers  come  suddenly,  quickly  destroying  the  gingivae  down  to 
the  alveolar  process,  but  seemingly  not  invading  it,  exposing  the 
roots  of  the  teeth  to  this  extent.  The  margins  of  the  ulcers  are  everted, 
crater-Hke,  somewhat  Hke  chancrous  ulcers.  The  base  of  the 
ulcers  is  overlaid  with  a  grayish-white  covering.  When  this  covering 
is  removed,  the  granulating  surface  bleeds  freely.  The  lymphatics 
related  to  the  area  become  enlarged,  and,  unlike  chancrous  lymphatic 
enlargements,  are  tender.  It  is  also  unlike  chancre  in  that  the  ulcers 
are  nearly  always  multiple  and,  exceedingly  painful  to  touch.  Saliva- 
tion is  much  increased,  with  frequent  drooling,  the  breath  is  fetid,  and, 
owing  to  the  absorption  of  toxic  elements,  there  is  a  slight  rise  in  tem- 
perature. The  contiguous  lingual  gingivae  become  reddened,  but  do 
not  participate  in  the  ulceration.  The  condition  has  been  mistaken 
for  syphilis." 

Therapeutics. — The  ordinary  local  remedies  used  for  somewhat 
similar  conditions  are  of  Httle  value  here  unless  systemic  treatment 
is  simultaneously  instituted.  Calomel  is  the  drug  to  give  internally, 
a  prescription  for  which  follows : 

I^ — Hydrargyri  chloridi  mitis,  gr.  ij  (0.13  Gm.) 

Sodii  bicarbonatis,  5  3  (4-o  Gm.) — M. 

Fiat  chartulee  No.  xx. 

Sig. — Take  one  powder  every  two  or  three  hours. 

The  local  treatment  consists  in  cleansing  the  ulcer  with  such 
agents  as  hydrogen  dioxid,  drying  the  part  and  applying  a  lo  per 
cent,  solution  of  silver  nitrate  or  a  20  per  cent,  solution  of  argyrol. 
If  the  ulceration  is  checked,  complete  restoration  of  the  gum  tissue 
by  granulation  follows.  Mouth  hygiene  should,  of  course,  be 
instituted  and  strenuously  carried  out. 

A  form  of  ulcerous  gingivitis,  somewhat  resembling  the  above 
condition,  frequently  occurs  in  the  mouths  of  young  people,  espe- 
cially young  men  who  are  addicted  to  the  habit  of  smoking.  The 
gum  in  the  interproximal  space  first  is  reddened,  this  being  quickly 
followed  by  necrosis  which  extends  around  the  teeth.  The  gingiva 
of  all  the  teeth  in  the  mouth  may  be  simultaneously  involved.  The 
disease  is  exceedingly  painful,  is  sometimes  accompanied  by  fever 
and  loss  of  flesh,  and,  by  the  dentist  who  called  almost  every  disease 
of  the  mouth  pyorrhea,  patients,  thus  afflicted,  have  frequently 
been  informed  that  they  were  suffering  from  the  latter  disease. 
Generally  in  these  cases  the  teeth  have  been  neglected,  so  far  as 
prophylaxis  is  concerned,  and  an  irritant  of  some  character  will  be 

30 


466  PRACTICAL   DENTAL    THERAPEUTICS 

found  about  the  necks  of  the  teeth  or  under  the  free  margin  of  the 
gums.  This  is  about  the  only  symptom  that  the  disease  has  in 
common  with  pyorrhea.  In  these  and  all  such  similar  cases  the 
highly  astringent  pyorrheal  remedies  should  not  be  employed.  What 
is  needed  here  is  a  thorough  prophylactic  treatment,  the  local  applica- 
tion of  mildly  stimulating  remedies,  such  as  a  25  per  cent,  solution 
of  argyrol,  and  the  daily  use  of  an  antiseptic  mouth  wash.  If  neces- 
sary, a  cathartic  should  be  prescribed.  With  the  above  treatment 
these  disagreeable  cases  yield  nicely. 

LUDWIG'S  ANGINA 

Ludwig's  angina  is  an  acute  infection  of  the  floor  of  the  mouth. 
Starting  from  a  surface  focus,  usually  within  the  mouth  and  in- 
significant, a  severe  infection  passes  to  the  submaxillary  lymph 
nodes,  where  it  takes  on  virulent  activity,  leading  to  an  extensive 
cellulitis  and  producing  a  very  hard,  tumor-like  mass  betw^een  the 
borders  of  the  mandible.  The  edema  frequently  extends  to  the 
larynx,  alarming  the  patient  because  of  the  difficulty  in  breathing. 

Diagnosis. — The  manifestation  of  the  above  described  symptoms 
would  lead  to  but  one  conclusion — ^Ludwig's  angina.  According  to 
Hofheinz,  the  symptoms  as  outhned  by  Ludwig  have  never  been 
questioned,  though  their  cause  has  been  much  disputed.  As  a  rule, 
there  is  very  Httle  constitutional  disturbance.  Ptyalism  may  be 
produced.  The  tongue  is  not  sensitive,  but  its  movement  causes 
pain. 

Therapeutics. — The  treatment  of  this  disease  had  better  be 
undertaken  by  an  oral  specialist.  Drainage  must  be  established. 
The  mouth  should  be  irrigated  every  two  hours  while  the  patient  is 
awake  with  a  warm  antiseptic  solution,  and  Brophy  advises  paint- 
ing the  throat  with  a  10  per  cent,  solution  of  iodin  in  glycerin. 
This  author  also  warns  us  against  the  extraction  of  a  tooth  which 
may  have  started  the  infection  until,  at  least,  the  acute  stage  has 
passed. 

GONORRHEA 

According  to  Burchard-IngHs,  undoubted  cases  of  oral  infection 
by  the  specific  germ  of  gonorrhea  {gonococcus)  have  occurred.  The 
author  has  seen  at  least  one  such  case.  The  mucosa  of  the  cheekSj 
gums,  tongue,  and  even  of  the  hard  and  soft  palates  may  undergo 
intense  suppuration.  Mouth  hygiene  and  the  systemic  treatment 
of  the  constitutional  trouble  cure  the  case.  ' 


DISEASES    OF    THE    SOFT   TISSUES    OF    THE   MOUTH  467 

There  are  a  variety  of  tumors  and  other  diseases  which  manifest 
themselves  in  the  mouth,  involving  both  the  soft  and  osseous  struc- 
tures, for  the  diagnosis  and  treatment  of  which  see  works  on  Oral 
Pathology  and  Surgery.  The  more  common  of  the  diseases  of  the 
soft  tissues  of  the  mouth  and  their  treatment  have  been  thus  briefly 
considered  here  with  the  hope  of  stimulating  a  greater  interest  in 
this  phase  of  mouth  diseases. 


EXAMINATION  OF  URINE^ 

1.  The  Sample. — That  passed  on  arising  in  the  morning. 

2.  Quantity. — In  24  hours  =  1,000  to  1,500  mils. 

3.  Condition. — Clear  or  sedimentary.  ^  Filter,  if  sedimentary, 
and  examine  color. 

4.  Color. — Pale  yellow,  yellow  (normal).  Reddish  yellow  (bile 
coloring).  Blood  red  (excess  of  urates).  Reddish  brown  (breaking 
up  of  blood-corpuscles). 

5.  Consistency. — Thin  (normal).  Thick,  syrupy  or  stringy 
(indication  of  sugar,  albumen,  pus  or  fibrin). 

6.  Reaction. — By  litmus  paper.  Mild  red  (slightly  acid,  nor- 
mal). Neutral  or  alkaline  (inflammatory  condition  of  urinary 
tract) . 

7.  Specific  Gravity. — With  urinometer.  1,015  to  1,025  (nor- 
mal), 1,015  or  below  (excess  of  water)  1,030  or  above  (excess  of  solids 
— urea  or  sugar). 

8.  Albumen. — (i)  Heat  Test. — Pour  urine  in  a  test-tube  to  2  in. 
in  depth.  Boil  gently,  heating  from  top  downward.  If  a  precipi- 
tate is  formed  it  is  either  (a)  earthy  phosphates  (soluble  in  acetic 
acid),  (b)  albumen  (insoluble  in  acetic  acid).  (2)  Nitric  Acid 
Test.- — To  2  in.  of  urine  in  a  test-tube,  held  slantingly,  add  five  to 
ten  drops  of  concentrated  nitric  acid  c.  p.,  permitting  it  to  run 
carefully  down  the  side  of  the  slanting  test-tube.  A  white  coagu- 
lum  at  the  zone  of  contact  of  the  two  liquids  indicates  albumen. 
To  eliminate  error,  both  the  heat  and  nitric  acid  tests  should  be 
made. 

9.  Total  Solids. — Multiply  the  last  two  figures  of  the  sp.  gr,, 
if  it  is  below,  1,018,  by  2,  the  coejficient  of  Trapp.  If  above  1,018 
by  2.33,  the  coefiicient  of  Haser.  This  gives  the  total  solids  in  1,000 
mils.  As  the  quantity  of  urine  passed  in  twenty-four  hours  is  about 
1,500  mils,  the  above  result  should  be  multipHed  by  i}'^,  which  will 
give  the  total  soHds  for  twenty-four  hours. 

^This  outline  was  condensed  by  Professor  J.  N.  Roe,  whom  the  author  assisted 
for  several  years  in  the  Chemic  Laboratories  of  the  Chicago  College  of  Dental  Surgery, 

^Set  sample  of  urine  aside  in  a  conical  glass  and  examine  the  sediment  with  a 
microscope. 

468 


EXAMINATION    OF   URINE 
TOTAL  SOLIDS  IN  NORMAL  URINE 

Excreted  in  T"wenty-four  Hours 


469 


Total  Solids. 


Constituents 


Grains 


60.0  to  70.0 


Urea 

Uric  Acid 

Creatinin 

Hippuric  Acid 

Chlorids 

Earthy  Phosphates. . 
Alkaline  Phosphates. 
Sulphates 


SO.O  to40.0 
o .  4  to  0.8 
0.5  to  i.o 
0.3  to    1.0 

10.0  to  IS. 0 

0 .  9  to    1.3 
2  •  3  to    3.5 

1 .  =;  to      2  .  T 


10.  Urea. — If  the  urine  is  above  sp.  gr.  1,025,  test  as  follows: 
Pour  exactly  2  in.  in  depth  of  urine  into  a  test-tube,  and  con- 
centrate just  one-half  by  boiling  gently  in  the  test-tube,  or  by  pour- 
ing into  a  porcelain  dish  and  concentrating  over  water  bath,  sand 
bath  or  wire  gauze. 

Pour  the  concentrated  urine  back  into  the  same  test-tube  and 
ascertain  if  it  is  concentrated  to  exactly  one-half  the  original  volume. 
Introduce  one- third  volume  of  concentrated  nitric  acid  c.  p.  (free 
from  red  or  yellow  fumes).  Place  the  test-tube  and  contents  in  a 
vessel  of  cold  water. 


A  precipitate  of 
Urea  Nitrate  is 
formed. 


a.  Immediately  (very  copious,  filling  the  entire 
volume  of  hquid) .     Excess. 

b.  After  twenty  minutes  (not  heavy).     Normal. 
^  c.  Not  after  several  hours.     Decrease. 

11.  Urates, — Pour  2  in.  of  urine  into  a  test  tube,  add  fifteen  to 
twenty  drops  of  concentrated  hydrochloric  acid.  Allow  the  mixture 
to  stand  twelve  to  twenty-four  hours.  The  urates  will  be  decom- 
posed, and  red  crystals  of  uric  acid  (corresponding  to  brick-dust 
deposit)  will  collect  in  the  bottom  and  on  the  sides  of  the  tube. 

The  crystals  on  the  sides  of  the  tube  may  be  loosened  with  a  little 
stick  or  glass  rod,  when  they  will  rapidly  settle  at  the  bottom. 

a.  Copious  (covering  bottom  of  tube).     Excess. 

h.  Moderate  (total  bulk  size  one-half  grain  of  wheat). 

Normal 
^  c.  Very  sHght.     Decrease. 

12.  Chlorids. — To  2  in.  of  urine  in  a  test-tube,  add  five  to  ten 
drops  of  nitric  acid  and  solution  silver  nitrate  by  drops  as  long  as 


The  Uric 
Acid  pre- 
cipitate is, 


h.  Moderate  {%  in.  in  depth).     Normal. 


470  PRACTICAL   DENTAL   THERAPEUTICS 

any  precipitate  forms;  shake  slightly  and  set  aside  for  a  few  moments 

to  settle. 

The    Silver    a.  Co/'^'ow^  (over  3^  in.  in  depth) .     Excess. 

Chlorid  pre- s  b.  Moderate  {}4  in.  in  depth).     Normal. 

cipitate  is,     [  c.   Slight  (less  than  above).     Decrease. 

13.  Sulphates. — To  2  in.  of  urine  in  a  test-tube,  add  five 
to  ten  drops  of  hydrochloric  acid  c.  p.  and  solution  of  barium  chlorid 
by  drops  as  long  as  any  precipitate  forms;  set  aside  and  allow  to 
settle. 

The   Barium    a.  Copious  (over  }4  in.  in  depth).     Excess. 
Sulphate  pre- 1  b.  Moderate  {}4  ^^-  in  depth).     Normal. 
cipitate  is,        [  c.  Slight  (less  than  above).     Decrease. 

14.  Earthy  Phosphates. — To  2  in.  urine  in  a  test-tube,  add 
ammonium  hydroxid  until  it  smeUs  strongly  of  ammonia;  heat 
gently  and  set  aside. 

The  Ammonio-  fa.  Copious  (over  %  in.  in  depth).    Excess. 
Magnesium 
and      Calcium  < 
Phosphates 
are,  I  c.  Slight  (less  than  above).     Decrease. 

15.  Alkaline  Phosphates. — Filter  the  Hquid  from  No.  14  into 
a  clean  test-tube  (or  prepare  another  specimen  as  above  and  filter), 
add  ten  drops  of  ammonium  chlorid  and  magnesium  sulphate  by 
drops  as  long  as  any  precipitate  is  formed.  Heat  gently  and  set 
aside  to  settle. 

The     Ammonio-  [  a.  Copious  (over  i^-^  in.  in  depth).     Excess. 

_,,        ,    ^  i     Moderate  (i}4  in.  in  depth).     Normal. 

Phosphate  pre- 
cipitate is,  [  c.   Slight  (less  than  above) .     Decrease. 

16.  Sugar. — Remove  any  trace  of  albumen  or  earthy  phosphates 
by^boiling  and  filtering.  Use  the  clear  filtrate.  Pour  into  a  test- 
tube  I  in.  of  Fehling's  solution  and  add  same  quantity  of  water. 
Boil  gently.  If  precipitate  is  formed,  filter;  when,  after  repeated 
boiling  and  filtering,  no  precipitate  is  formed,  add  urine  and  heat  as 
before. 

No  change  in  color  =  No  sugar. 
Slight  change  to  dirty  green  =  Trace  of  sugar. 
Bright  yellow  =  Sugar  over  i  per  cent. 
Red  =  Excess  of  sugar. 

In  case  it  is  desired  to  have  a  microscopic  and  bacteriologic  ex- 
amination of  the  urine,  the  specimen  may  be  sent  to  a  Pathologic 


EXAMINATION    OF   URINE 


471 


Laboratory,  these  are  now  in  every  large  city.  But  every  dentist 
should  be  prepared  to  make  physical  and  chemical  examinations, 
according  to  the  outHne  here  given.  The  results  of  the  analysis 
should  be  recorded  and  preserved.  This  may  be  done  in  the  following 
form : 

URINE  ANALYSIS 

Name, 

Date, 


Physical  Characters. 

Amoiunt  in  24  hours,- 

Specfic  gravity, 

Condition, . 

Color, 


Consistency, - 


Chemic  Characters. 

Reaction  with  litmus,- 
Reaction  with  heat, 


Reaction  with  nitric  acid, 
Total  solids, 

Urea, 


Urates, 

Chlorids, 

Sulphates, 

Earthy  phosphates,  _ 
Alkaline  phosphates, 
Abnormal  constituents. 

Albumin, 

Sugar, 


Clinical  Memoranda. 


FEHLING'S  SOLUTION 


FehUng's  Solution  is  made  by  mixing  exactly  equal  volumes  of  the  below- 
mentioned  copper  solution  and  alkaline  solution  at  the  time  required. 

Copper  Solution: 
Crystallized  copper  sulphate,  34-64  gm. 

Sterihzed  distilled  water,  sufficient  quantity  to  make  500  mils. 

Alkaline  Solution: 
Potassium  sodium  tartrate  (Rochelle  salt),  173  gm. 

Potassium  hydro xid,  125  gm. 

Sterilized  distilled  water,  sufficient  quantity  to  make  500  mils. 

These  solutions  should  be  kept  in  well-stoppered  bottles,  in  a  cool,  dark 
place,  and  mixed  only  at  the  time  needed.  If  a  precipitate  forms  when  the  cold 
solutions  are  first  mixed,  it  should  be  dissolved  by  agitating  the  test-tube;  and  no 
precipitate  should  form  when  the  mixed  solutions  are  heated.  By  keeping 
the  copper  solution  and  alkaline  solution  in  separate  bottles  in  a  cool,  dark  place, 
they  shovdd  keep  without  change  almost  indefinitely;  however,  it  is  best 
to  have  fresh  solutions  prepared  at  least  once  a  year. 


GENERAL  INDEX 


ABDERHALDEN  on  inorganic  iron, 
182 
Abrasions,  139,  147,  302,  304 
Abscess  alveolar,  acute,  108,  iii,  160, 
192,  219 
chronic,  96,  370 

between  roots,  391 
caries  in,  379 

caused  by  toothpick,  393 

cavity,  57 

dental,  early  treatment  of,  357 

dento-alveolar,  64,  65,  82 

drainage  of,  369 

due  to  blow,  392 

in  deciduous  teeth,  390 

involving  several  teeth,  381 

lancing  of,  127,  141,  143 

of  both  antrums,  303 

of  frontal  sinus,  303 

pericemental,  391,  393 

pocket,  secondary,  381 

pulpal,  308,  350 

rupture  of,  353 

treatment  of,  192,  219,  370 
by  ionization,  347 

with  sinus,  373 
Absorbent  cotton,  20 
Absorption  of  drugs,  22 
Abstracts,  14,  15 
Acacia,  121 
Acetanilid,  146,  147 

powder,  effect  of,  on  heart,  171 

prescriptions  for,  367 
Acetic  acid,  97 
Acetozone,  90,  409 
Acetphenetidin,  147 
Acetyl-paramino-phenyl  salicylate,  47 
Acetyl-salicylic,  47 
Acid,  acetic,  97 

benzoic,  31 

boric,  31 

cambogic,  221 

gallic,  35 

hydrochloric,  97 

hydrocyanic,  178 

hydrofluoric,  105 

lactic,  99 

"method,"  344 

mineral,  33 

monochloracetic,  98 

nitric,  96 

oleic,  II 

osmic,  33 

oxalic,  92 

phenolsulphonic,  94,  95 

phosphoric,  dilute,  189 

salicylic,  45 

sulphuric,  94,  340 


Acid,  sulphurous,  31,  32,  93,  214 

tannic,  31,  72,  74,  329 

treatment,  96 

trichloracetic,  33,  98,  288 
Acids,  organic,  6 
Acne,  90 
Aconite,  113 

poisoning,  114,363 
Aconitina,  113 
Actinomycosis,  464 

_  treatment  of,  80,  193,  464 
Active  principles  of  drugs,  5,  15 
Adenitis,  200 
Adrenal  chlorid  combined  with  cocain, 

134 
Adrenalin,  77 

chlorid  for  hemorrhage,  323 
objections  to,  323 

combined  with  cocain,  138 
Age  a  factor  in  dosage,  28 
Agglutinins,  247 

Air,  compressed,  in  dentistry,  251,  286, 
288 

purifier,  90 
Air-thrombosis,  23 
Albolin,  120 
Albumin,  coagulation  of,  63,  64 

in  urine,  468 
Alcohol,  abuse  of,  in  dentistry,  299 

as  antiseptic,  169 

as  disinfectant,  279 

dehydrated,  166 

diluted,  166 

for  relief  of  pain,  368 

modified,  168,  279,  299,  346 

official  standard  for,  166 

physiological  action  of,  167 

therapeutics  of,  168 
Alcoholism,  acute,  differentiation  of,  167 

chronic,  168 
Alcresta  ipecac  in  pyorrhea  alveolaris, 

437 
tablets,  232 
Alkali-metals,  104 
Alkalies,  poisoning  by,  98 
Alkaline  powder,  38 

solution,  471 
Alkaloids  as  medicines,  5 
Allspice,  239 

Aloes,  Barbadoes  and  Socotrme,  210 
Aloin,  211 
Alpha-eucain,  137 
Alphozone,  91,  409 
Alteratives,  30,  181 
Alum,  ammonium,  78 

potassium,  78 
Aluminum  chlorid  as  a  bleacher,  404 

siHcate,  hydrated,  125,  437 


473 


474 


INDEX 


Alveolar  abscess,  acute,   extraction  of 
tooth  in,  368 
treatment    of,    by    magnesium 
citrate,  219 
by  potassium  iodid,  192 
chronic,  96,  370 

bone  involvement  in,  378 
complications  of,  372,  376,  389 
evacuation  of  pus  from,  377 
involving  vault,  380 
necrosis  in,  379 
sequelce  of,  382 
sinus  in,  98,  373 
treatment  of,  370,  373,  389 
surgical,  382 
diagnosed  by  radiograph,  344 
external  opening  of,  373 
from  broken  toothpick,  393 
process,  exfoliation  of,  326 
exposed  after  extraction,  139 
hypertrophy  of,  373 
removal  of,  385 
resorption  of,  376,  421 
purulent,  347,  370,  374,  410 
without  sinus,  370 
Amalgam  fillings,  196,  305,  386,  403 
Ameba,  pathogenic,  diseases  due  to,  233 
Amebae  in  pyorrheal  pockets,  436 
Ammonia,  2,  169 

as  heart  stimulant,  132 
gas  in  pulp  decomposition,  336 
physiologic  action  of,  1 70 
poisoning,  170 
Ammonio-magnesium      and      calcium 
phosphates,  470 
phosphate  precipitate,  470 
Ammonium  acetate,  solution  of,  230 
bromid,  155 
carbonate,  170 
chlorid,  234 
hydrogen  fluorid,  436 
iodid,  193 
Amputation  of  root-end,  435 
Amygdalin,  178 
Amylopsin,  206 
Amyl  nitrite,  poisoning  by,  173 

therapeutics  of,  1 74 
Analgesics,  30,  126,  291 
Anchorage  for  filling,  314 

occlusal,  300 
Anemia,  iron  in,  182,  185 

pernicious,  202 
Anesthesia,  advocates  of,  284 
cocain,  130 

conductive,  25,  130,  138,  289 
discovery  of  ,  283 
high-pressure,  289 
interosseous,  289 
local,  23,  25,  130 
oxid-oxygen,  355 
pressure,  25,  136,  315,  318,  319 
prolonged,  141 
tranquil,  161 
Anesthetics,  30,  126 

for  curetting  abscess,  383 
general,  126,  140 
local,  126,  137,  289 
safest,  140 


Anesthetization  by  cataphoresis,  324 

in  removal  of  pulp,  315 

solution,  317 

under  pressure,  319 
Aneurysm,  contraindications  in,  173 
Angina,  Ludwig's,  466 

pectoris,  202 
Animal  tissue,  action  of  thymol  on,  54 
Anise,  239 

Anisotonic  solution,  216 
Anodynes,  30,  291 

general,  291 

in  pulp  removal,  322 

local,  126,  289 
Antacids,  30 

in  oral  prophylaxis,  36 
Antagonism  of  drugs,  31,  276 
Anthelmintics,  31 
Antibodies,  246,  247,  255 
Antidote  for  arsenic,  39,  102,  185,  186, 

329 

for  digitalis,  173 

for  gelsemium,  180 

for  hydrofluoric  acid,  106 

for  iodin  poisoning,  118 

for  mineral  poisons,  37,  97 

for  opium  poisoning,  159 

for  phenol,  169,  375 

for  phosphorus,  188 

for  silver  nitrate,  87 

for  strychnin  poisoning,  165 

in  corrosive  poisoning,  105 

physiologic,  276 
Antimony  and  potassium  tartrate,  233 
Anti-Narcotic  'Law,  133,  136,  160 
Antipyretics,  31,  145,  147 
Antipyrin,  action  of,  145,  146 
Antisepsis  in  canal  filling,  396 

of  mouth,  throat,  nose,  69 
Antiseptics,  31,  41,  271 
Antispasmodics,  31 
Antitoxins,  5,  246,  255 
Antral  cavity,  washing  of,  414 
Antrum,  abscess  of,  380,  382,  388 

diseases  of,  410,  412 
diagnosis,  412 
due  to  trauma,  412 
from  catarrhal  inflammation,  412 
from  dental  conditions,  410 
treatment  of,  by  rhinologist,  413 
medicinal,  414 
surgical,  413 

foreign  bodies  in,  252,  412 

healthy,  importance  of,  413 

of  Highmore,  410,  414 

opening  of,  painless,  414 
Apexotomy,  385 
Apicoectomy,  385,  389 
Apomorphin,  5 

hydro  chlorid,  231 
Apoplexy   distinguished  from   alcohol- 
ism, 167 
Apothecaries'  weight,  257,  258 
Appendicitis  due  to  pyorrhea,  419 
Appliances  for  loose  teeth,  440,  441 

for  replanted  teeth,  435 
Argyria,  86 
Argyrol,  87 


INDEX 


475 


Aristol,  56,  313 

Arnica,  61 

Aromatic  spirit  of  ammonia,  170 

waters,  9 
Arsenic  albuminate,  328 

as  escharotic,  100 

compound,  as  specific  for  syphilis, 

457 
compounds  of,  201 

poisonous  action  of,  94 
metallic,  201 
poisoning  by,  57,  94,  186,  326 

acute  and  chronic,  loi 

local,  57,  100 

systemic,  1 01 
preparations  of,  201,  326 
toleration  for,  in  Austria,  100 
trioxid,  99,  201 

a  cause  of  pericementitis,  359 

application  of,  327 

as  an  escharotic,  94 

as  devitalizing  agent,  325 

in  desensitizing,  284 

poisoning,  local,  334 
white,  99 
Arsenical  pigments,  inhalation  of,  loi 
Arsenous  acid,  99 
Arterial  hyperemia,  307 

pressure  reduced   by  paraldehyd, 

154 

Arthritis,    chronic,    treatment    of,    by 
vaccines,  248 

Asepsis,  41 

absolute,  in  operation,  361 
during  pulp  decomposition,  338 
in  pulp  removal,  322,  328 
in  root-canal  work,  169,  396 

Asphyxia  from  ether,  142 
prevention  of,  151 

Aspirin,  promiscuous  use  of,  47 

Aspirol,  170 

Assay  of  drugs,  13,  15 

Assaying,  indicator  in,  215 

Asthma,  inhalations  of  niter  in,  227 

Astringents,  31,  72 
mineral,  72 
pyorrhea,  428,  429 
vegetable,  72 

Atropin,  161,  175,  176,  229 
poisoning  by,  176 

Aurantium,  241 

Avoirdupois  weight,  257,  258 

BACILLUS  diphtherias,  245 
fusiform,  417 
tetani,  245 
tubercle,  462 
Bacteria  a  cause  of  pericementitis,  358 
action  of  alcohol  upon,  168 
ctiltures  of,  247 
destruction  of,  42,  277 
entrance  of,  into  body,  245 
in  mouth,  309,  453 
in  pyorrheal  pocket,  416 
multiplication  of,  417 
toxicity  to,  65 
Bacterins,  248 
Bacteriolysins,  247 


Bacteriotropins,  247 

Balsam  of  Peru,  45 

Band,  fitting  of,  349 

Bandages,  20 

Barium  sulphate  precipitate,  470 

Baths,  Russian  and  Turkish,  249 

Bay-rum,  239 

Beck's  paste,  85 

compressed  air  apparatus,  286 
Belladonna,  161,  175 

action  of,  physiologic,  176 
liniment,  12,  177 
Benzoic  acid,  44 
Benzosulphinid,  243 
Benzoylacetyl  dioxid,  90 
Berberin,  76 

Beta-eucain,  hydrochlorid,  137 
Betanaphthol,  58 
Bichlorid  of  mercury,  198 

tablets,  18 
Bicuspid,  second,  excementosed,  351 
"Biliousness,"  197,  222 
Biologic  processes,  5 

products,  245 
Bismuth  paste,  388 

in  antral  disease,  414 
healing  of  wound  over,  379 
poisoning,  85 
subnitrate,  84 
Bitter  tonics,  177 
Black  copper  oxid,  81 
Black's  1-2-3  mixture,  50 
Blaud's  pills,  185 
Bleachers,  31,  88,  214 
Bleaching  agents,  404 

of  teeth,  70,  88.  90,  93,  98,  190,  403 
applications  for,  93,  405,  406,  408 
by  oxidation,  88,  404 
by  reduction,  88,  405 
principles  of,  403 
Blindness  in  United  States,  86 
Blood,  abnormal  substances  in,  444 
coagiilability  of,  84 
count  in  pyorrhea,  418 
corpuscles,  white,  action  of  quinin 

on,  366 
deficiency  of  water  in,  216 
hemoglobin  of,  181 
-pressure,   action    of   digitalis  on, 
172 
relief  of,  175 
removal  of,  320 
-serum,  salinity  of,  215 

substitute  for,  179 
stream,  bacteria  in,  245,  418 
Blue  light,  treatment  by,  251,  287 
Boils,  127,  205 
Bone  cell  stimulant,  345 
phosphate,  189 
pus  formation  in,  380 
regeneration  of,  356,  393 
removal  of,  by  maUet,  385 
tissue,  loss  of,  121 
Bones,  action  of  phosphorus  on,  187 
Boracic  acid,  43 
Borax,  38,  39,  44 
Boric  acid,  43 
Borism,  43 


476 


INDEX 


Boroglycerin,  gl3^cerite  of,  117 

Breath,  fighting  for,  130 

Bridge  and  retainer,  combination,  432 

inlay,  decay  under,  354 
Bridgework,  295,  303,  443 
Broach,  broken,  252 

selection  of,  320 
Bromids,  the,  154 

as  analgesics,  292 
Bromism,  154 
Bronchial  catarrh,  52,  235 
Bronchitis,  acute,  225 

chronic,  193 

terebine  in,  112 
Brown  mixture,  12 
Brucin,  action  of,  163 
Bruises,  treatment  of,  61,  75,  120,  144 
Brushing  of  teeth,  429 
Bunge  on  organic  iron,  182 
"Burning"  process,  342 
Burns  from  hydrofluoric  acid,  436 

treatment  of,  37,  38,  60,  83-,  118, 
120,  147 
Butyl-chloral  hydrate,  152,  450 

CACAO-BUTTER,  129 
Caflfein,  action  of,  171 
as  diuretic,  223 
Calcific  deposits,  314,  332 
Calcification  of  pulp,  332 
Calcium  carbonate,  precipitated,  36 

chlorid,  84 

hydroxid,  37 

hypophosphite,  190 

phosphate,  effect  of,  on  nutrition, 
190 
paste,  51,  407 
precipitated,  189,  312 
thymolized,  312,  390 

sulphurated,  204 
Calculus,  serumal,  419 
Calendula  and  calendulin,  60 
Callahan's  method,  95,  344 

rosin  solution,  iii,  400 
Calomel,  action  of,  physiologic,  197 

idiosyncrasy,  27 

incompatability  of,  198 
Camphor,  114,  115 
Camphors,  derivation  of,  6 
Canadin,  76 
Canals,  blocking  of,  347,  352 

exposure  of,  319,  328 

filling  of,  III,  322,  383,  398 

gangrenous,  99,  340 

moistening  of,  342,  396 

obliteration  of,  303,  332,  447 

preparation  of,  for  filling,  336 

removal  of  blood  from,  32 1 

small  and  tortuous,  321,  399 
Cancer  of  stomach,  206 

of  tongue,  70 

superficial,  253 
Cancrum  oris,  81 
Cane-sugar,  243 
Canker  sores,  51,  64,  69,  80,  98,  184,  454 

differentiated        from  mucous 

patches,  458 
Cannabis  indica,  161 


Cantharides  and  cantharidin,  112 
Capillaries,  depletion  of,  366 
Capillary  attraction,  absorption  by,  116 

oozing,  146,  169 
Capping  of  pulp,  190,  308 
Capsicin  and  capsicum,  108 
Capsicum,  oleoresin  of,  16 
Capsules,  213,  271,  367 
Caraway,  240 

Carbohydrates  as  medicines,  5 
Carbon,  60 

dioxid,  evolution  of,  97 

in  drugs,  5 
Carborundum  stones,  427,  428 
Carbuncles,  205 

Carcinoma  on  leucoplakia  patch,  463 
Cardamom  seed,  238 
Cargentos,  88 
Caries,  dental,  96,  244,  314,  379 

exploration  for,  380 

removal  of,  97,  311 
Carlsbad  salt,  artificial,  218 
Carminatives,  31,  237 
Carr  instruments,  423 
Carron  oil,  37,  119 
Cascara  sagrada,  208 
Cases,  history  and  treatment  of,  351 
Castings,  442 
Castor  oil,  212,  213,  451 
Cataphoresis,  26,  254,  287 

in  pulp  removal,  324 
Catarrh,  chronic,  37,  77 
Cathartics,  32,  208 

saline,  215,  217 
Caustic,  lunar,  85 

potash,  104 

pyrozone,  90,  392 
as  a  bleacher,  407     • 
as  an  escharotic,  409 

soda,  104 
Caustics,  33,  93 

desensitizing,  287 

for  bleaching  teeth,  98 
Cauterization,  205,  250,  348,  374 

after  hemorrhage,  323 

in  abscess  cases,  392 
Cautery,  actual,  106 

electric,  330 
Cavity,  excavation  of,  293,  294 

gingival,  290,  295 

packing  of,  for  bleaching,  406 

preparation  of,  141,  143,  283,  300 
painless,  289,  294 

sealing  of,  295 

sensitive,  251,  328 

sterilization  of,  mechanical,  316 
Cement,  copper  phosphate,  81 

for  sealing,  300,  365 

zinc  oxychlorid,  83,  394,  399 
phosphate,  189 
Cementum  exposed,  cauterizing  of,  205 
irritation  from,  302 
sensitive,  86 
Centigrade  scale,  250 
Cephaelin,  232,  437 
Cerates,  19 

Chafing,  powder  for,  125 
Chair,  dental,  dread  of,  154 


INDEX 


477 


Chalk,  precipitated,  36 

prepared,  36 
Chancre,  syphilitic,  70,  76,  456 
Chancroids,  96 
Change  of  life,  445 
Charcoal,  animal  purified,  60 

as  deodorant,  60 

poultice,  20 
Chartas,  20 
Chemico-mechanical  cleansing  of  canal, 

340 

process,  345 
Chemistry,  principles  in,  274 
Chewing,  effect  of,  on  saliva,  236 
Chilblains,  170 

Childhood,  spasmodic  disorders  of,  151 
Children,  dosage  for,  28 

febrile  affections  of,  230 

hypersensitive  dentin  in,  290 

pulp  removal  in,  333 
Children's  teeth,  cement  for,  81 

treatment  of,  390 
Chinosol,  70 
Chip-blower,  362 
Chips,  clearing  away  of,  251 
Chloral  camphor,  152 

hydrate,  29,  150 
as  hypnotic,  151 
poisoning  by,  151 
Chlorbutanol,  139 
Chloretone,  139 
Chlorin,  92 

nascent,  404 
Chlorinated  lime,  92 

soda,  92 
Chloroform,  142 

as  analgesic,  143,  291,  292 

contraindications  for,  144 

dangers  of,  143,  292 

habit,  144 

in  canal-filling,  398,  401 

narcosis,  62 

physiologic  action  of,  143 

therapeutics  of,  143 

use  of,  cautions,  143 
Chloropercha,  124,  143 
Chlorosis,  182,  211 
Cholera  morbus,  214 
Christian  Science,  256 
Chromic  acid,  102 
Chromium  trioxid,  102 
Cinchona,  148 

Cinchonidin  and  cinchonin,  148 
Cinchonism,  149,  150 
Cineol,  49,  5i-  397 
Cinnamic  aldehyd,  49 
Cinnamon,  oil  of,  49 

water  spray,  169 
Circulation,  pericemental,  433 
Citrus  aurantium  and  vulgaris,  241 
Cleanliness  of  mouth,  459 
CHmate,  influence  of,  on  drug  action,  29 
Cloves,  oil  of,  50 
Coal-tar  antipyretics,  147 
Coca,  128 
Cocain,  action  of,  paralyzant,  130 

anesthesia,  fatahties  from,  130 
local,  129 


Cocain,  as  protoplasmic  poison,  289,  318 
by  hypodermic,   author's  formula 

for,  135 
combined  with  adrenalin,  138 

with  arsenic,  133 
experiments  in,  129,  130 
habit,  132 

hydrochlorid,  5,  128,  129,  136 
billets  of,  136 
dosage  of,  maximum,  135 
hypodermic  use  of,  133 
solutions  of,  135 
idiosyncrasy,  27,  132,  134 
points,  136,  317 
-poisoning,  131,  134 

treatment  of,  132,  169,  276. 
sloughing  from,  134 
substitutes  for,  136 
susceptibility  to,  131 
therapeutics  of,  133,  136 
Cocaina,  128 
Codein,  156,  157 
Cod-liver  oil,  action  of,  restorative,  191 

in  emaciating  diseases,  191 
Coffee  in  narcotic  poisoning,  171 
Coil,  dry-cell  vibrating,  253,  338 
Cold,  application  of,  to  sensitive  den- 
tin, 286 
as  therapeutic  agent,  250 
cream,  39,  243  . 
in  the  head,  235 
physical  law  concerning,  290 
sores,  83,  124,  455 
Colds,  treatment  of,  52,  241 
Colitis  due  to  pyorrhea,  419 
Collapse,  23,  26,  173,  178 
from  anesthetics,  176 
CoUargol,  88 
Collodion,  11,  123 
cantharidal,  124 
flexible,  124 
styptic,  73,  124 
CoUyrium,  81,  272 
Color  molecule,  breaking  up  of,  405 
of  tooth,  320,  321 

preservation  of,  320,  329,  402 
restoration  of,  338,  402 

by  caustic  pyrozone,  392,  409 
Coloring  agent,  244 
Colycynth,  220 

fatal  irritation  from,  221 
Compound  licorice  powder,  212 
Compounds,  ferrous,  185 

miscellaneous,  6 
Compressed  air,  251,  286,  288 
Conductive  anesthesia,  25,  130,  138,  289 
Cone  flower,  203 
Cones,  fitting  of,  398,  399 
Confections,  17 

senna,  209,  210,  21 1 
Confidence  of  patient,  255,  423 
Congestion,  cerebral,  croton  oil  in,  220 
Conjunctivitis,  81,  87 
Conservativeness  of  dentists,  413 
Constipation,    chronic,    118,   209,   210, 
211,  212,  221,  222 
due  to  rhubarb,  213 
in  children,  210 


478 


INDEX 


Constructive  diseases,  302 
Convalescence  in  exhaustive  diseases, 

200 
Convolvulin,  221 
Convulsions  in  childhood,  151,  230 

in  strychnin  poisoning,  164 

in  tetanus,  174 
Convulsions,  relief  of,  174 
Copper  cement  for  filling,  386 

oxid,  81 

solution,  471 

sulphate,  80 
as  emetic,  188 
in  actinomycosis,  464 
Coriander  oil,  211,  240 
Corns,  removal  of,  46,  98 
Correctives,  237 
Corrosive  sublimate,  198 

as  an  alterative,  197 
Corrosives,  93 
Corj'za  involving  antrum,  412 

treatment  of,   115,   120,   160,   176, 
229 
Cotton  for  filling  root-canals,  394 
Cottonseed  oil,  119 
Cough,  122 
Counterirritants,  34,  58,  106,  108 

refrigerant,  362 
Counterirritation,  remedial  effect  of,  107 
Cracks  in  feet  and  hands,  86 
Cream  of  tartar,  224 
Creosote,  66 
Cresol  as  diluent,  338 

as  disinfectant,  65 
Croton  oil,  220 
Croup,  115 
Crown,  gold,  302,  304 

perfect,  mutilation  of,  432 

porcelain,  302,  355,  375 

setting  of,  painful,  133 
Crowned  teeth,  abscesses  of,  355 
Crowning,  dangers  of,  314 
Cudbear,  tincture  of,  244,  425,  427 
Curettement  of  abscess,  375,  382,  389 
hemorrhage  in,  383 
incision  for,  383 
Currents,  electric,  253 
Cusps,  grinding  of,  362 
Cyanosis  from  nitrous  oxid,  292 
Cystic  fluid  differentiated  from  serum, 

372 
Cysts,  periapical,  372,  382 

r^AKIN'S    hyperchlorous   acid    solu- 

^-^         tion,  179 

Dandruff,  212 

Dead  pulp,  diagnosis  of,  338 

Death  from  use  of  cocain,  130 

chloroform,  143,  144,  292 

ethyl  chlorid,  128 

hydrogen  dioxid,  69 

opium,  160 
Decay  of  teeth,  rapid,  190 
Deciduous  molar  roots,  resorption  of, 

333 

teeth,  abscess  in,  390 

pulps  of,  gangrenous,  390 
removed,  333 


Decoctions,  13 
Deformities,  nasal,  121 
Delirium  tremens,  168 
Demulcents,  32,  116 
Dental  liniment,  362,  363 

author's,  447 
Dental  pastes,  potassium  chlorate  in,  226 
pulp,  diseases  of,  298 
sterilization,  277 
therapeutics,  281 
Dentifrices,  32 
Dentin,  blood  in,  320 

desensitizing  of,  128,  138,  288,293, 

295 
hypersensitive,  283,  284 
infected,  sterilizing  of,  199,  201 
obtunding  of,  53,  142,  251,  254 
by  cold,  286 
by  heat,  285 
by  physical  agents,  285 
protection  of,  404 
secondary,  302,  332 
sensitive,  53,  142,  251,  254,  285 

treatment  of,  84,  293 
sensitiveness  of,  thermal,  283 
sterilization  of,  201,  294,  310,  316 
Dentist  and  physician,  relations  of,  349, 

443 

right  of,  to  prescribe,  267,  450 
Dentistr}^,  painless,  25,  27,  133,  283 
Dentition,  temporary,  151,  155 
Denture,  red-rubber,  196 
Denuded  roots,  433 
Deodorants,  32,  41,  70 
Deoxidation,  93 
Deposit  encircling  tooth,  419 

removal  of,  423,  425,  431,  436 

salivary,  420 
Desensitization  of  dentin,  128,  138,  288, 

293, 295 
Desensitizing  paste,  55,  138,  141,  293, 
297 
on  exposed  cementum,  432 
precautions  in  using,  295 
Desquamation  due  to  formaldehyd,  68 
Destructive  diseases,  306 
Devitalization  of  pulp,  315,  325,  326 
by  formocresol,  329 
technic  of,  327 
Dextrins  and  dextrose,  244 
Diabetes  mellitus,  202 

teeth  in,  421 
Diagnosis  by  radiograph,  252,  345 

mistake  in,  391,  432,  433 
Diaphoretics,  32,  228 
Diarrhea,  46,  142 

inflammatory,  212,  214 

treatment  of,  by  salol,  46 
Diastase,  207 
Diathesis,  hemorrhagic,  76 

rheumatic,  421 

uric  acid,  228 
Digestants,  205,  206 
Digestive  tract,  toxins  in,  453 
Digitalein  and  digitalin,  172 
Digitalis,  172 

action  of,  cumulative,  172 
physiologic,  172 


INDEX 


479 


Digitalis,  as  diuretic,  223 

poisoning  by,  173 

preparations  of,  standardization  of 
172 

therapeutics  of,  173 
Digitin,  digitonin  and  digitoxin,  172 
Di-isobutyl-cresol-iodid,  56 
Diluent  of  powders,  16 
Diphtheria  bacillus,  245 
Diphtheria,  resorcin  in,  59 

toxins  of,  245,  246 
Dipsomaniacs,  168 
Direct  oxidation,  404 
Discharge,  syphilitic,  456 
Disclosing  solutions,  428 
Discoloration  of  teeth,  73,  182,  392,  402 
by  fracture,  409 
by  iron  tannate,  329 
by  potassium  permanganate,  70 
causes  of,  402,  403 
pink,  402 
Disease,  treatment  of,  rational^  281 
Diseases,  constructive,  302 

destructive,  306 
Disinfectants,  33,  41 

surgical,  71 
Disinfection  by  alcohol,  279 

by  cresol,  65 

by  formaldehyd,  67 

by  mercury,  71,  198 

in  dentistry,  279 

of  hands,  91,  92 

of  rooms,  68 

of  site  of  operation,  279 
Dispensatory,  4 
Dissolution,  3 
Di-thymol-di-iodid,  56 
Diuretics,  33,  222 
Dobell's  solution,  271,  430 
Donovan's  solution,  199,  200,  201 
Dosage,  28,  267 
Dover's  powder,  157,  232,  243 
Drastics,  32,  208 
Dressings,  antiseptic,  21 

fixed,  116 
Drilling,  dangers  of,  284,  320 

into  innocent  teeth,  373 

of  teeth,  painless,  284,  286 
Dropsy,  general,  222,  227 
Drug,  definition  of,  i,  4 
Drug-habit,  27 

irritants,  358I 

poisoning,  121,  240,  249,  276 
Drugs,  action  of,  2,  27,  285,  359 

added  to  root-fillings,  395 

administration  of,  21 
by  hypodermic,  22 
by  inhalation,  26 
by  inunction,  25 
by  mouth,  21 
by  rectum,  26 
intravenous,  26 
time  of,  29 

antagonism  of,  276 

antidotes  to,  275 

chemic  tests  of,  275 

coagulating,  336 

effects  of,  2,  27,  359 


Drugs,  effects  of,  cumulative,  28,  172 
in  pathologic  conditions,  29 
local,  126 

for  local  use,  36 

general,  36 

incompatibility  of,  274,  275,  276 

inorganic  and  organic,  5 

masking  taste  of,  122 

miscellaneous  group  of,  1 79 

neutral  principles  of,  6 

sources  of,  4 

standardizing  of,  172 

to  be  prescribed  alone,  275 

vegetable,  4 
Dry  gangrene  of  pulp,  350 
Dysentery,  amebic,  233,  436 

tropical,  436 
Dyspepsia,  atonic,  206 

flatulent,  60 
Dysphagia,  210 

pCHAFOLTA,  203 

■*-'     in  cases  of  infection,  366 

Echinacea,  203,  204 

therapeutics  of,  204 
Eczema,  acute  erythematous,  125 

ointment  for,  197 

treatment  of,  by  talc,  125 
Edema  of  larynx,  466 
Effervescent  salts,  17,  366 
Ehrlich's  discovery  of  "606,"  456,  45; 
Electrargol,  88 
Electricity  as  a  nerve  stimulant,  253 

as  therapeutic  agent,  253,  287 

in  neuralgia,  448 
Electric  mouth  lamp,  86,  252 
Elixirs,  11 

Elongation  of  tooth,  358 
Emboli,  gaseous,  a  cause  of  death,  69 
Emetics,  33,  230, 

ammonium  alum,  78 

in  str>"chnin  poisoning,  165 

mustard,  no 

tepid  water,  234 
Emetin,  hemostatic  action  of,  438 

hydrochlorid,  232 

treatment  in  pyorrhea    alveolaris, 
436,  438 
Emodin,2ii 
Emollients,  33,  115 
Empirical  therapeutics,  i 
Emulsifying  agents,  12,  121 
Emulsin,  178 
Emulsions,  12 
Enamel,  brilliancy  of,  428 
Encystment  of  root,' 378 
Endameba  buccalis,  417,  436 

histolytica,  436 
Enema,  administration  of,  26 
Epidermic  medication,  25 
Epilepsy  akin  to  alcoholism,  168 

convulsions  of,  155 
Epinephrin,  77 
Epispastics,  107 
Epsom  salt,  215,  217 
Equimolecular  concentration,  216 
Ergot,  76 

in  pregnancy,  28 


48o 


INDEX 


Eriodictyon,  aromatic  syrup  of,  366 
Erosions,  302 

saliva  in,  236 
Eruptions,  syphilitic,  458. 
Erythroxylon  coca,  128 
Eschar  of  sulphuric  acid,  344 

production  of,  94 
Escharotics,  33,  93 

cautious  use  of,  105 

desensitizing,  287 
Esophagus,  piercing  of,  97 
Essences,  10 
Ether,  141 

as  analgesic,  291 

contraindications  of,  142 

inflammability  of,  141 

inhalation  of,  142 

making  of,  275 

narcosis,  62 

spray, 142 
Ethyl  alcohol,  166 

bromid,  dangers  of,  144 

chlorid,  127,  250 
as  analgesic,  291 
inflammable  vapor  of,  127 
use  of,  fatal,  128 
Eucain,  137 
Eucalyptol,  51 

and  gutta-percha  solution,  124 

compound,  52,  346 
formula  for,  360 
use  of,  for  abscess,  371 

for  moistening  canals,  359 

solvent  power  of,  396,  397 

with  thymol,  372 
Eucapercha,  396 
Eugenol,  50,  239 

for  sensitive  dentin,  291 
Euroform  paste,  58,  387 

in  abscess,  379 

in  arsenical  poisoning,  335 
Europhen,  56,  313 
Examination  of  urine,  468 
Excipient  for  pills,  17 
Excitement,  nervous,  153 
Excoriations,  120 
Excretions,  stimulation  of,  365 
Exfoliation   from    arsenical    poisoning, 

326 
Expectorants,  33 

sedative,  233,  234 
Experiments  with  phosphorus,  187 
Explosion,  caustic  pyrozone,  408 

ether,  141 

nitric  acid,  96 

silver  nitrate,  87 

sulphuric  acid,  96 
External  use,  preparations  for,  18 
Extract,  powdered,  14 
Extraction  of  teeth  by  specialists,  140 

deciduous,  143 

hemorrhage  following,  74 

in  antral  diseases,  413 

in  cases  of  abscess,  368 

in  mercurial  poisoning,  194 

painful  sockets  after,  139 

painless,  137 

unnecessary,  390 


Extraction,  products  by,  12,  13 
Extracts,  assay  of,  15 

pilular,  15 

solid,  13,  15 
Exudates,  absorption  of,  108 
Eyes  of  baby,  sore,  86 
Eye-wash,  boric  acid,  43 


UACIAL  neuralgia,  444,  445,  451 
■*■       Fahrenheit  scale,  250 
Family  physician,  case  of  syphilis  re- 
ferred  to,  457,  458 

collaboration  with,  281,  448 
Paradic  current,  253 
Fat  a  product  of  putrefaction,  407 

as  source  of  energy,  191 

digestion  of,  191 

supply  of,  in  body,  191 
Fats  in  dentistry,  6 

Federal   Anti-Narcotic  Law,    27,    136, 
160,  450 

Narcotic  Law,  27,  133 

record  blank,  449 
Feet,  hyperidrosis  of,  73,  79 
Fehling's  solution,  471 
Fennel,  240 

Ferment,  albuminous,  207 
Fermentation,  acids  of,  38 

in  the  mouth,  244,  431 
Ferric  chlorid,  184 

compound,  182,  183 

hydroxid  with  magnesium  oxid,  185 

hypophosphite,  186 

oxid  a  cause  of  discoloration,  407 

subsulphate,  184 
Ferrous  carbonate,  185 

compound,  182,  183 

iodid,  186 

ions,  183 

sulphate,  183 
Ferrum  dialysatum,  185 
Fever  sores,  455 
Fiber,  devitalizing,  354 
Field  of  operation,  dry,  1 76 
Fig  as  a  laxative,  209 
Filling  materials,  drugs  added  to,  395 

metallic,  302 

of  teeth,  painless,  284 

root-canals,  336,  394,  399 
Filter,  charcoal  as,  60 
Filth  disease,  464 
Fissures,  protective  for,  123 
Fistulae,  salivary,  103 
Flatus,  prevention  of,  237 
Flavored  masses,  17 
Flavoring  agents,  10,  239,  240 
Flaxseed  poultice  and  tea,  119 
Flowers  of  sulphur,  214 
Fluid  extracts,  14 
Fomentations,  20 

Food  and  Drugs  Act,  National,  4,  136 
Foods,  definition  of,  34,  181 

preservative  of,  43 
Foot-bath  in  pericementitis,  366 
Foramina,  sealing  of,  400 
Foreign  bodies,  expulsion  of,  231 


INDEX 


481 


Formaldehyd,  67 

as  antidote  for  arsenic,  329 

chemic  changes  produced  by,  337 

gas,  generation  of,  338 

treatment  of  gangrenous  pulp,  337 

use  of,  cautious,  371 
Formalin,  67 
Formocresol,  345 

dressing,  339,  352 

for  devitalization,  329 

in  treatment  of  abscess,  370 
pulpal,  350 
purulent,  347 

remedy,  66,  68 
Formol,  67 

Fowler's  solution,  201,  202,  223,  242 
Fracture  of  jaw,  252,  409 
Fractures,  pain  of,  159 
Fuller's  earth,  125 
Fumes  of  phosphorus,  186 
Fungous  growths,  96,  98 
Fusibility  of  preparations,  1 8 


GALLIC  acid,  73,  74 
Galvanic  current,  253 
Gamboge,  221 
Gangrene  of  pulp,  308,  350,  364,  390 

in  deciduous  teeth,  390 

treatment  of,  390 
Gangrenous  root-canals,  99,  336 
Gargle,  chinosol,  71 

for  sore  throat,  81,  272 
Gas  in  alimentary  canal,  237 
Gases,  conversion  of,  into  liquids  and 
solids,  67 

noxious,  from  chloroform,  143 

of  decomposition,  337,  339 
Gastric  catarrh,  85,  218 

digestion,  189 

juice,  38 

stimulants,  177 

ulcer,  85,  206 

due  to  pyorrhea,  418 
Gauze,  euroform,  380 

medicated,  21 
Gelseminin  sulphate,  180 
Gelsemium,  180 

poisoning,  180 
Genito-urinary  diseases,  suppurative,  68 
Gentian,  177 
Gentio  picria,  177 
Germicides,  33,  41 
Germs  of  disease,  245 
Gin,  Holland,  166 
Ginger,  preparations  of,  238 
Gingivitis,  419 

acute,  ulcerous,  87,  464 

distinguished  from  pyorrhea,  466 

in  pyorrhea,  425 

interstitial,  416 
Glands,  mucous,  stimulation  of,  236 

suprarenal,  77 

thyroid,  78 
Glass  containers,  disinfection  of,  279 
Glonoin,  174 
Gloves,  rubber,  460 
Glucose,  244 


Glucosides,  5 

Glycerin,  116 

Glycerite  of  tannic  acid,  73 

Glycerites,  11 

Glyceryl  trinitrate,  174 

Glycyrrhiza  and  Glycyrrhizin,  122 

Gold  and  sodium  chloride,  205 

crowns,  302 

inlay,  392 

scrap,  refining  of,  227 
Gonorrhea  of  mouth,  466 
Gout,  use  of  lithium  for,  228 
Gouty  diathesis,  202 
Granulation  tissue,  254 
Granulations,  exuberant,  79,  86,  105 

treatment  of,  70 
Granulomas,  dental,  96,  106,  344 

non-purulent,  344,  345,  351 

treated  by  ionization,  347 
Grape  juice,  pure,  fermented,  166 
Green  soap,  tincture  of,  40,  119 
Gregory's  powder,  213 
Growths,  smaU,  removal  of,  184 
Guaiacol,  66 
Gummata,  460 
Gums,  brushing  of,  429 

derivation  of,  6 

hypertrophy  of,  98,  103,  106,  330 

inflamed,  75,  83,  117 

lacerated,  57,  60 

recession  of,  38,  420,  421 

slitting  of,  434 

sloughing  of,  334 

solubility  of,  6,  274 

spongy,  61,  73,  75,  416 
Gun  cotton,  123 
Gutta-percha,  124 

addition  of  drugs  to,  395 

and  eu'-alyptol  solution,  124 

cones,  399 

filling,  52,  333 

for  deciduous  teeth,  390 
for  root-canals,  386,  394,  399 

hermetic  sealing  with,  408 

points,  279,  357,  397 

solvents,  359,  395 

use  of,  injudicious,  300 

white  base-plate,  396 

HABIT,  drug,  27 
Haematoxylon  campechianum,  75 
Hallberg  on  metric  system,  261,- 262 
Hamamelis  Virginiana,  75 
Hands,  chapped,  117,  122 

disinfection  of,  91,  92,  397 

lotion  for,  243 

of  dentist,  abraded,  124 
puncttu-ed,  124 
Harrison  Narcotic  Act,  27 
Headache,  53,  115,  162,  171 

nervous,  449 
Healing  by  first  intention,  60 
Heart  failure,  sudden,  170 

stimulants,  163 

tobacco,  162 
Heat,  application  of,  249,  285 

as  a  counterirritant,  108 


482 


INDEX 


Heat,  as  a  disinfectant,  71 

in    the    treatment    of    pericemen- 
titis, 363 
Hematics,  35,  181 
Hematinics,  181,  183,  185 
Hematoxylon,  75 
Hemoglobin  in  tubuli,  402 
Hemophilia,  76,  84 

Hemorrhage  after  extraction  of  teeth, 
184 
removal  of   hypertrophied  gum, 
330 
capillary,  169 
intestinal,  74 
persistent,  84 
post-partum,  76 
prevention  of,  78,  323,  324 
profuse,   after  pulp  removal,   98, 
320,  323 
arrest  of,  84 
secondary,  323 
small,  79,  84 

treatment  of,  with  salt  solution,  178 
Hemostatics,  35,  72 
Henbane,  160 
Herbs  used  for  drugs,  7 
Herpes  gingivalis,  455 

labialis,  455 
Hexamethylenamin,  68 
Highmore,  antrum  of,  410 
Hoarseness,  122 

Hine,  Dr.  C.  L.,  splint  suggested  by,  440 
Hoffmann's  anodyne,  142 
Honeys,  11,  210 
Horse,  antitoxin  from,  247 
Hydrastin  and  hydrastina,  76 

hydrochlorid,  76 
Hydrastis  canadensis,  76 

preparations  of,  77 
Hydragogues,  32,  208 
Hydrargyrum,  193 
Hydrated  chloral,  150 
Hydrobromic  ether,  144 
Hydrochloric  acid,  97 
Hydrocyanic  acid,  178 
Hydrofluoric  acid,  105 
Hydrogen  dioxid,  69,  90 

as  a  bleaching  agent,  407 
as  a  mouth-wash,  70 
ethereal  solution  of,  407 
explosion  of,  408 
in  pulp  removal,  321 
sulphid  in  pulp  decomposition,  336, 

337 
Hyoscin  hydrobromid,  160 
Hyoscyamin  hydrobromid,  160  ' 
HyoScyamus,  160,  161 
Hyperacidity  of  stomach,  38 
Hyperemia  of  pulp,  307,  308 
treatment  of,  308,  313 
production  of,  254 
Hyperidrosis  of  feet  and  hands,  73,  79, 

Hyperisotonic  solutions,  216 
Hypertrophy  of  gums,  98,  103,  106,  330 

of  piilp  tissue,  332 
Hypnotics,  34,  150 
Hypnotism,  256 


Hypodermic  injection,  fright  due  to.  135 
into  vein,  23 
technic  of,  24 
irrigation  of  sinus,  374 
medication,  indications  for,  22 
syringe,  varieties  of,  24 
Hypoisotonic  solution,  216 
Hypophosphites,  syrup  of,  186,  190 


ICE,  application  of,  250 
as  local  anesthetic,  128 

-bag,  355 
Idiosyncrasy  to  cocain,  131,  134 

to  drugs,  27 

to  potassium  iodid,  192 

to  quinin,  150 
Immunity,  acquired  and  natural,  246 
Impacted  teeth,  252 
Impotence,  functional,  188 
Impression,  compound,  440 
Incompatibility,  chemic   and  [physical, 
274 

in  prescriptions,  274 

of  antipyrin,  146     _ 

of  potassium  bromid,  155 

of  sodium  bicarbonate,  38,  275 

of  tannic  acid,  74 

physiologic,  276 

therapeutic,  276 
Incompatible  drugs,  list  of,  275 
Indian  hemp,  161 
Indirect  oxidation,  404 
Infection,  alveolar,  germs  found  in,  378 . 

focus  of,  82 

removal  of,  349,  351,  389 

mixed,  due  to  extraction,  368 
from  ulcer  formation,  107 

of  face  and  jaws,  125 

of  mucous  patches,  458 

open  wound,  280 

root-end,  106 

septic,  a  cause  of  sloughing,  134 
from  hypodermic  injections,  23 

streptococcus,  248 

syphQitic,  455,  459,  461 
Infectious  diseases,  therapy  of,  245 
Infiltration  anesthesia,  25,  383 
Inflammation  as  natural  process,  365 

of  pulp,  307 

pericemental,  124 
Infusions,  13 
Inhalation  of  arsenic,  in  dust,  loi 

of  chloroform,  143,  292 

of  drugs  or  liquids,  26 

of  ether,  142 

of  ethyl  chlorid,  127 

of  nitrite  of  amyl,  174 
Injections,  hypodermic,  24 

intraneural,  103 

intravenous,  178 
Injury  from   careless  instrumentation, 

423 
Insect  bites,  118 
Insomnia,  151 

from  grief,  relieved  by  sulphonal, 

153 
Instrument  tray,  426 


INDEX 


483 


Instruments,  boiling  of,  38,  41 

for  curettement,  384,  385 

for  piilp  removal,  319 

for  scaling,  425 

in  syphilitic  cases,  460 

Logan-Buckley,  423-426,  431 

metal,  effect  of  mercury  on,   199, 
201 
oxygen  on,  406 

rusting  of,  278 

sterilization  of,  38,   71,  201,  278, 
^  383,  397,  426 
by  paraform,  68 
by  resorcinol,  59 
Interosseous  anesthesia,  25 
Intestines,  absorption  of  drugs  in,  22 
Intoxication,  acute,  167 
Inunction,  25 
lodin,  55 

as  antiseptic,  57 

as  counterirritant,  58 

as  disinfectant,  280 

compound  solution  of,  334,  363 

discoloration,  57,  58 

poisoning,  118 

stimulation  by,  334,  387,  435 

use  of,  In  bone  affections,  435 
lodism,  57,  192 
Iodoform,  55 

action  of,  57 
lodol,  56 
Ionic  medication,  106 

_  theory,  348 
Ionization,  106,  347 
Ipecac,  232 

root,  preparations  of,  436 
Iron  carbonate,  185 

compounds,  182,  183 

deficiency  of,  182 

dialysed,  185 

objections  to,  329,  335 

injurious  to  teeth,  186 

iodid,  186 

masked,  183 

metallic,  181,  182 

organic,  182 

perchlorid,  184 

quinin,  and  strychnin  phosphate, 
450 

reduced,  185 

tannate,  329 
Irritants,  34,  106,  358 

mechanical,  360 
Irritation,  reflex  peripheral,  444 
Isopilocarpin,  229 
Isotonic  solutions,  133,  179,  216 
Itching,  53 

TABORANDI,  229 
*J     Jalap,  preparations  of,  221 
Japanese  bibulous  paper,  398 
Jaundice,  catarrhal,  218,  231 
Jaws,  operations  about,  139 
Joint  affections,  170 
Juices  of  plants  as  drugs,  8 

KALIUM,  104 
Kaolin,  117,  125 
Keefe's  suction  apparatus,  255 


Kirk's  bleaching  mixture,  93 

reduction  process,  405 
Koller,  introduction  of  cocain  by,  129 
Krameria,  preparations  of,  74 

triandra,  74 

T  ABARRAQUE'S  solution,   92,   404 
^  405 

Laboratory,  biologic,  245 

pathologic,  454 
Lactation,  medication  during,  29 
Lactic  acid,  99 
Lactose,  243 
Lanolin,  120 
Laryngitis,  59,  79 
Larynx,  edema  of,  170 
Latin,  medical,  268 
Laudanum,  156 
Laughing  gas,  140 
Lavender,  preparations  of,  242 
Laxatives,  32,  208 
Lead  acetate,  79 

filling,  387 

poisoning,  80,  217 
croton  oil  in,  220 
Leeching,  255 
Lemon  juice  in  scurvy,  241 
Leucocytes,  action  of,  255 
Leucoplakia  buccalis,  463 
"Life-saver,"  396 

Light  as  remedial  agent,  251,  287,  463 
Lime,  chlorinated,  92 

liniment,  12 
Lime-salts,  189 
Lime-water,  37 
Liniments,  12,  272 

ammonia,  170 

belladonna,  175 

camphor,  115 

chloroform,  143 

dental,  formula  for,  362 

for  pericementitis,  114 

soft  soap,  119 
Linimentum  calcis,  37,  119 
Linseed,  119 

Lips,  dry  and  cracked,  82 
Liquids,  poisonous,   of  decomposition, 

337      . 
Liquor  antisepticus,  43,  55 
formtda  for,  430 
cresolis  compositus,  65 
Lithium  carbonate,  227 

citrate,  228 
Liver,  sluggish,  197 
Logan-Buckley   instruments,    423-426, 

431 
Logan  crown,  432 
Loose  teeth,  prognosis  for,  422 
Lozenges,  17 

"L.-Suprarenin  Synthetic,"  77 
Lucodescent  light,  251 
Ludwig's  angina,  466 
Lugol's  solution,  55,  192,  363 
Lumpy-jaw,  464 
Lunar  caustic,  85 
Lupus  vulgaris,  253 
Lycopodium,  125 
Lysol,  65 


484 


INDEX 


MACE,  238 

^"1     Magnesia,  calcined,  39 

heavy  and  light,  39 
Magnesium  carbonate,  39 

citrate,  219 

solution  of,  formula  for,  365 

oxid,  39 

silicate,  124 

sulphate,  215,  217 
Malaria,  salvarsan  in,  202     • 

quinin  a  specific  in,  150,  450 
Malignant  growths,  pain  of,  159 
Malt,  206,  207 
Malted  liquors,  166 
Manna  and  mannite,  209 
Marshmallow,  122 
Massage  in  dentistry,  254,  429 
Masses,  17 

Materia  medica,  definition  of,  i 
Maxilla,  fracture  of,  409 
Maxillary  sinus,  relation  of  molar  roots 
to,  411 

sinusitis,  87 
Measures,  approximate,  259 
Mechanical  irritants,  358,  360 
Medication,  epidermic,  25 

hypodermic,  22 

ionic,  106 
Medicines,  classification  of,  29 
Melancholia,  hypnotic  in,  162 
Membrane,  pericemental,  358 

semipermeable,  216 
Menstruation  and  canker  sores,  454 
Menstruum,  12 
Mental  healing,  256 
Menthol  for  headache,  53 

for  sensitive  dentin,  291 
Mercurial  stomatitis,  194,  226,  272,  461 
Mercuric  chlorid,  71,  198,  199 

iodid,  red,  199 

poisons,  196 

sulphate-ethylenediamin,  200 
Mercurol,  200 
Mercurous  chlorid,  mild,  197 

iodid,  yeUow,  200 
Mercury,  193 

absorption  of,  194 

action  of,  cumulative,  194 
physiologic,  194 

as  specific  for  syphilis,   195,  457, 
458,  459 

atoxylate  of,  457 

bichlorid,  198 

biniodid,  199 

compounds  of,  195,  196 
organic,  195 

in  dental  amalgams,  196 

inunctions  of,  195,  196 

iodid,  green,  200 

nucleinate,  200 

poisoning  by,  194,  196,  461 

protiodid,  200 

succinimid,  438 

systemic  disturbance  from,  196 

therapeutics  of,  195 
Metal  die,  125 

Metallic  potassium  and  sodium,  340 
Metaphosphoric  acid,  188 


Meter  as  unit  of  linear  measure,  260 

Methemoglobin,  146 

Methyl  meta-amino-para-oxybenzoate, 

139 

Methyl  trichlorid,  142 
Metric  system,'257,  259 
advantages  of,  262 
measures  of  capacity,  261 
weights,  261 
Metrology,  257 
Microorganisms,  245 
Migraine,  152,  162,  171 
Milk  of  sulphur,  214 
Mineral  acid,  neutralizing  of,  96 
poisoning,  97 
waters,  natural,  218 
Mitchell's  "rest  cure,"  254 
Mixtures,  11 

of  soUds,  16 
Model,  coating  of,  125 

wax,  441 
Moisture,  removal  of,  397 

in  canals,  342,  359 
Molars,  pericemental  abscess  of,  392 
Money,  decimal  system  of,  260 
Monochloracetic  acid,  98 
Monsel's  salt  and  solution,  184 
Morphin,  action  of,  local,  158 
anhydrous,  156 
for  neuralgia,  449 
habit,  159 

prescription  for,  449 
salts  of,  157 
Mouth  and  stomach,  relations  of,  453 
aphthous  sore,  87 
bacteria  in,  309,  364 
diseases  of,  283,  453 
disinfection  of,  45 
hygiene  of,  309,  459 

after  operation,  387 
infection  of,  gonorrheal,  466 
-lamp,  electric,  412 
rubber  sore,  75 
secretions  of,  236 
syphilitic  symptoms  in,  458 
tissues  of,  hard,  283 

soft,  453 
-washes,  antiseptic,  117 
astringent,  72,  236,  429 
cinnamon,  50 
dangers  of,  70 
for  pyorrhea,  430,  431 
Mucilages,  12 

Mucoperiosteum,  penetration  of,  _4io_ 
Mucous    membrane,    hypodermic    in- 
jection through,  25 
inflammation  of,  80,  86,  123 
morbid  conditions  of,  193 
oral,  77,  453,  459 
tuberculosis  of,  462 
ulceration  of,  99 
patches,  syphilitic,  98,  103,  458 
Mucus,  secretion  of,  234 
Mustard,  black  and  white,  109 
blisters  from,  no 
paper,  20 
Mydriatics,  34 
Myocardialdegeneration,  220 


INDEX 


485 


Myotics,  34 
Myrosin,  109 
Myrrh,  61 
Myrtol,  235 


NARCEIN,  156 
Narcotic  poisoning,  81,  171,  176 
electricity  in,  253 
Narcotics,  34,  156 

federal  law  concerning,  27, 133, 136, 
160,  449,  450 
Narcotile,  127 
Narcotin,  156 
Nasal  cavity,  abscess  under,  380 

deformities,  correction  of,  121 
Nausea  due  to  cocain,  135 
from  ipecac,  437 
in  taking  impressions,  66,  133 
National  Formulary,  4 
Natrium,  104 
Narcosis,  62,  156,  159 
Necrosis  in  gingivitis,  465 
maxillary,  188 
of  bone,  96,  121,  379 
Neosalvarsan,  99,  202 
Neothesin,  138,  291,  294 
Nerve  blocking,  130,  138,  451  _ 
Nerve,  inflammation  of,  chronic,  444 
sheath,  inflammation  of,  444 
tissue,  regeneration  of,  451 
Neuralgia,  444 

agonizing,  451 
causes  of,  444 
'   due  to  anemia,  202 
general  diseases,  444 
pulp  nodule,  305 
facial,  113,  114,  445 
intractable,  444 
malarial,  450 
obscure  cause  of,  302 
of  fifth  nerve,  188 
persistent  ^  103 
rheumatic,  449 

treatment  of,  108,  no,   145,   161, 
177,  181,  273,445 
anodyne,  448,  449 
by  alcohol  and  cocain  anesthesia, 

452 
by  counterirritation,  124,  143 
by  injections  of  alcohol,  451 
by  liniments,  447,  448 
by  menthol,  53 
by  morphin,  159,  449 
by  quinin,  150 
by  salicylates,  46,  48 
general,  448 
local,  447 
medicinal,  447 
surgical,  451 
systemic,  448 
trifacial,  152,  180 
trigeminal,  107 
with  pyorrhea  alveolaris,  177 
Neurasthenia,  phosphorus  in,  188 
Neuritis,  220 
Neurocain,  136 
Nervine,  181 


Nervous  diseases,  treated  by  arsenic,  99 
prostration,  massage  in,  254 
system,  action  of  alcohol  on,  167 

Nicotin  poisoning,  162 

Niter  paper  inhalations,  227 
sweet  spirit  of,  230 

Nitric  acid,  96 

Nitrites  as  heart  stimulants,  174 

Nitrogen  monoxid,  140 

Nitroglycerin,  174,  366 

Nitrous  oxid,  62,  128,  140 
as  analgesic,  292 
combined  with  oxygen,  414 

Nodules,  ptdp,  95,  332 

Nosophen,  56 

Novocain  hydrochlorid,  137 
as  local  anesthetic,  25,  137 
for  hypersensitive  dentin,  290 

Nutgall,  72 

Nutmeg,  237 

Nutrition,  effect  of  calcium  phosphate 
on, 190 

Nux  vomica,  163,  165 


OCCLUSION,  faulty,  361,  420,  445 
Odontalgia,  51 
Odor,  significance  of,  371 
"Official"  remedies,  4 
Oil,  camphorated,  115 

cod-liver,  191 

cottonseed,  119 

croton,  220,  222 

of  cajuput,  49,  397 

of  cassia,  49 

of  cinnamon,  49 

of  cloves,  50,  357 

for  sensitive  dentin,  291 

of  eucalyptus,  51 
commercial,  359 

of  myristica,  238 

of  myrtle,  235 

of  peppermint,  52 

of  theobroma,  129 

of  thyme,  54 

of  turpentine,  110 
Oils,  essential,  6,  10 

fixed,  6 

volatile,  6,  48,  238 
Ointment,  tannic  acid,  73 
Ointments,  18,  19 
Oleate  of  cocain,  290 
Oleates,  11 
Oleoresins,  natural,  6,  16 

pharmaceutic,  16 
Olive  oil,  118 
Operations  about  jaws,  139 

bloodless,  384 

minor,  anesthesia  in,  127,  141,  144 
Ophthalmia  neonatorum,  86 
Opisthotonos,  164 
Opium,  156 

action  of,  physiological,  157 

as  analgesic,  292 

contraindications,  for,  160 

denarcotized,  156 

elimination  of,  158 

habit,  158,  159 


486 


INDEX 


Opium,  poisoning,  158,  159,  160 

distinguished    from    alcoholism, 

167 
treatment  of,  159 
Opsonic  index,  439 
Opsonins,  247,  255 
Orange,  preparations  of,  241 
Organic  dioxids,  91 

peroxids,  91 
Orthoform,  139 
Orthophosphoric  acid,  188 
Osmic  acid,  103,  451 
Osmium  tetroxid,  103 
Osmosis,  process  of,  216 
Osseous  system,  action  of  phosphorus 
on,  187 

tissues,  tonic  for,  188 
Osteitis,  97 

Osteoma,  cause  of,  373 
Osteomalacia,  188,  190 
Overwork  a  cause  of  insomnia,  153 
Oxalic  acid,  92 

Oxidation  as  bleaching  agent,  404 
Oxidizing  agents,  direct,  88, 
indirect,  88,  92 

mixtiire,  227 
Oxids,  metallic,  solutions  of,  il 
Oxygen,  61 

as  a  bleacher,  62 

combined  with  nitrous  oxid,  141 

nascent,  liberation  of,  89,  408 
power  of,  407 
Ozone,  62 

PAIN  after  pulp  removal,  361 
control  of,  methods  for,  284 
from  cutting  of  bone,  387 
in  septic  pericementitis,  367 
"killer,"  159 
of  drilling,  251 
relief  of,  by  anodynes,  126 
by  opium,  159 
by  pyramidon,  148 
immediate,  361 
severe  paroxysms  of,  447 
Painless  dentistry,  25,  27,  133,  283 
Palate,  soft,  destroyed  by  gummata,  460 
Pancreatin,  206 
Papain,  207 
Papaverin,  156 
Paraffin  filHng  for  root-canals,  394 

injections  of,  121 
Paraform,  67 
Paraformaldehyd,  67 
Paraldehyd,  153 
Paralysis  of  fibrillae,  289,  294 
Paralyzant  agents,  126  ■ 

Parasiticide,  199 
Paregoric,  157 
Parillin,  203 

Parts-by-weight  system,  257 
Paste,  antiseptic,  395,  396 
arsenic  trioxid,  327 
desensitizing,  55,  138,  141,  293,  297 
devitalizing,  120 
for  filling  root-canals,  394 
for  pulp -capping,  51 
orthoform  and  europhen,  139 


Paste,  sodium  and  alcohol,  321 

thymolized  calcium  phosphate,  312 
Patches,  leucoplakia,  463 

mucous,  86,  98,  103,  458 
Pearson's  solution,  201 
Pediculosis  pubis,  196,  199 
Pepper,  black,  237 
Peppermint,  oil  of,  52 
Pepsin,  205,  206 
Percentage  in  solutions,  263 
Pericemental  abscess,  391 
therapeutics  of,  391 
membrane,  circulation  in,  433 
regeneration  of,  392 
Pericementitis,  apical,  67,  114,  359 
causes  of,  52,  317,  318,  358,  360 
counterirritation  in,  107,  109,  113, 

143,  362 
home  remedies  for,  363 
nonseptic,  due  to  irritants,  358 
liniment  for,  114 
treatment  of,  no,  358,  361 
by  aconite,  363 
by  heat,  363 
septic,  358,  364 
causes  of,  364 
diagnosis  of,  364,  365 
treatment  of,  by  drugs,  365 
by  heat,  108 
by  menthol,  53 
general,  365 
local,  364 
Persio,  244 

Peruvian  bark,  yellow,  148 
Petrolatum  and  petronol,  120 
Pharmaceutic  preparations,  8 
Pharmacodynamics,  i 
Pharmacology,  definition  of,  i 
Pharmacopeia,  United  States,  3,  4 
Pharmacy,  3 
Pharyngitis,  59,  75,  87,  98 

chronic  and  subacute,  79,  235 
Phenacetin,  147 
Phenol,  action  of,  62,  63 
as  analgesic,  287 
as  local  anodyne,  291 
compound,  54,  311,  427 
for  hermetic  sealing,  375 
in  pulp  treatment,  299 
poisoning,  46,  63,  217 
Phenolphthalein,  215 
Phenolsulphonic  acid,  94,  95 
advantages  of,  343,  345 
as  cleansing  agent,  340 
as  stimulant,  372 
in  pulp  removal,  322 
in  pus  pockets,  435 
in  treatment  of  abscess,  375,  392 
indications  for,  96 
neutralizing  of,  381 
syringe  for,  381 
Phenyl  salicylate,  46 
Phosphoric  acid,  188 
Phosphor-necrosis,   protection    against, 

188 
Phosphorus,  186 

action  of,  physiologic,  187 
inflammability  of,  187 


INDEX 


487 


Phosphorus,  poisoning,  187 

therapeutics  of,  188 
Physicians    and    dentists,    harmonious 

work  of,  349,  443 
Phthisis,  treatment  of,  by  arsenic,  99 

by  terebene,  112 
Picropodophyllin,  222 
Pigment  a  cause  of  discoloration,  403 
Pills,  17,  271 

aloes  and  iron,  211 

cathartic  compound,  197 

rhubarb  compound,  211 

vegetable  cathartic,  221 
Pilocarpin,  effect  of  atropin  on,  229 
Pilocarpus,  229 
Pimenta,  239 
Pinus  palustris,  no,  in 
Piperin,  237 

Plants,  parts  of,  used  for  drugs,  7 
Plaster-of- Paris  bandages,  21 
Plasters,  19 

capsicum,  109 

mustard,  20 
Plastic  porcelain  filling,  121 
Pockets,  deep,  elimination  of,  434 

lingual,  380,  388 

pyorrheal,  85,  98,  417 

curettement  of,  431,  432,  439 
location  of,  434 
Podophyllin  and  podophyllotoxin,  222 
Podophyllum,  222 
Poison,  definition  of,  3 

tablets,  18 
Poisoning,  acetanilid,  146 

aconite,  114 

alcohol,  167 

ammonia,  170 

amyl  nitrite,  173 

arsenical,  39, 100,  loi,  185, 186,  326 
local,  334    .,, 

aspirin,  47 

atropin,  176 

bismuth,  85 

by  alkalies,  98 

by  corrosives,  105,  118,  121 

by  depressant  drugs,  165,  173 

by  mineral  acids,  37,  97 

cantharides,  112,  113 

caustic  potash,  105 

chloral,  151 

cocain,  131 

digitalis,  173 

gelsemium,  180 

hydrofluoric  acid,  106 

iodin,  118 

lead,  80 

mercurial,  194,  196,  461 

metallic,  chronic,  193 

narcotic,  81,  no,  176 

nicotin,  162 

opium,  158 

oxalic  acid,  37 

paraldehyd,  154 

phenol,  63 

phosphorus,  fatal,  188 

potassium  bromid,  154 
chlorate,  226 

strychnin,  164 


Poisons,  anatagonists  to,  31 

expulsion  of,  231 
Polishing  of  teeth,  428 
Polypi,  nasal,  removal  of,  75 
Porcelain  body,  125 

filling,  121,  297 

jacket  crowns,  302,  355 
Posolog^',  28 

Posture  when  inhaling  chloroform,  292 
Potash,  caustic,  104 
Potassium  acetate,  224 

and  sodium,  104 
metallic,  340 
tartrate,  219 

bicarbonate,  223 

bitartrate,  224 

bromid,  154,  155 

carbonate,  223 

chlorate,  225,  226 

citrate,  224 

dichromate,  103 

hydroxid,  104 

iodid,  192 

action  of,  cumulative,  192 

physiologic,  192 
in  tertiary  syphilis,  460 

ion,  224 

nitrate,  227 

permanganate,  70 

in  opium  poisoning,  159 
incompatibility  of,  70 
Poultices,  20 

ice,  128 

kaolin,  125 
Powders,  16,  270 

dusting,  116,  125 
Practical  cases,  history  of,  351 

treatment  of,  351 
Precipitates,  formation  of,  274 
Pregnancy,  a  factor  in  dosage,  28 

and  ergot,  76 

mouth  secretions  in,  40 

purgation  in,  28 
Prescription,  basis  of,  266 

official  formula  in,  269 

refilling  of,  160 

-writing,  264,  269 
abbreviations  in,  264 
by  the  dentist,  267 
in  Latin,  268 
Prescriptions,  incompatibility  in,  274 

practical,  270 
Pressure  anesthesia,  25,  136,  315,   318, 

319 

for  pulp  removal,  392 
'     instruments  for,  319 

from  abnormal  growths,  444 

in  pulp  removal,  318 

osmotic,  216 
Prinz's  isotonic  solution,  134 
Privies,  deodorant  for,  184 
Probing  for  caries,  379 

sinus,  373  _ 

Process,  de\'italization  of,  334 

exposed,  after  extraction,  57 

removal  of,  surgical,  335 
Prophylaxis,  dental,  421  _ 

in  pyorrhea  alveolaris,  427 


48S 


INDEX 


Proprietary-  local  anesthetics,  136 
Protargol,  87 
Protectives,  116 

Protozoon  a  cause  of  pyorrhea,  417 
Prune  as  a  laxative,  210 
Prunus  virginiana,  178 
Pruyn's  method,  342 
Psoriasis,  simulation  of,  68 
Psychotherapy,  256 
Psychrotin,  232 

Ptomains  in  pulp  decomposition,  337 
Ptyalin,  secretion  of,  arrest  of,  72 
Ptyalism,  61,  75,  194,  461 
Pulmonarj-  tuberculosis,  67 
Pulp,  anesthesia  of,  25,  26,  254,  289 
blood-vessels  of,  298,  299 
calcification,  332,  352 
capping,  factors  in,  308 
pastes  for,  51 
technic  of,  310,  311 
chamber,  opening  of,  319,  328,  339 

pus  in,  339,  357 
dead,  diagnosis  of,  252,  253,  307, 

338 
decomposition  a  cause  of  discolora- 
tion, 402 
end-products  of,  67,  337,  340 
dehcacy  of,  300,  311 
devitalization  of,  102,  160,  207,  298, 

.      314 
diseases  of,  destructive,  306 

diagnosis  of,  296,  298 
exposure,  308,  309,  310 

by  accident,  354 

in  the  young,  309 
function  of,  314 
gangrene  of,  350,  364,  390 

diagnosis  of,  308 

in  a  child,  390 

specific  for,  66 

treatment  of,  353,  390 
■with  oil  of  myrtle,  236 
with  phenolsulphonic  acid,  96 

with  sinus,  373 
hyperemia  of,  307 
irritation  of,  299,  312 

mechanical,  314 
nodules,  95,  303,  305,  332,  361 

in  neuralgic  case,  305 

radiographs  of,  304 
normal,  anatomj-  of,  298 

sacrifice  of,  306 
partially  aUve,  350 
pathology,  296 
poisoning  of,  329 

remnant,  destruction  of,  90,  95,  105 
removal,  98,  136,  296,  298,  315,  320, 
431 

after-treatment,  322 

complications  of,  330 

from  deciduous  tooth,  333 

indications  for,  314,  431 

painless,  323 
septic,  308,  350 
slow  death  of,  312 
stimulation  of,  48 

tissue,  decalcified,  141 
digestion  of,  207 


Pulp,  tissue,  hypertrophy  of,  103,  332 
treatment  of,  298 
vital,  removal  of,  314 
Pulpal  abscess,  308,  350 
Pulpitis,  anodyne  for,  152 

associated  \^ith  pericementitis,  324 
diagnosis  of,  309 
treatment  of,  by  phenol,  64 
true,  307,  313 
Pulpless  teeth,  compHcations  of,  349 
diagnosis  of,  336 
sequelse  of,  336 
treatment  of,  336,  339 
by  acid  method,  344 
by  formocresol,  345 
Punctures,  protective  for,  123 
Purgatives,  32,  208 
Purshianin,  208 
Pus,  burrowing  of,  373 
disposing  of,  370 
evacuation  of,  204,  372,  377 
from  abscess,  370 
mechanical,  374 
formation,  causes  of,  364 

checking  of,  371,  372,  378 
pockets,  cauterization  of,  435 
pyorrheal,  diseases  due  to,  418 
examination  of,  416 
Putrescence,  true,  350 
Putrid  sore  throat,  70 
Pyorrhea  alveolaris,  416 

a  cause  of  pulp  removal,  315 

antiseptic  in,  82 

causes  of,  active  and  predisposing, 

416 
classes  of,  419 

systemic,  421,  443 
cure  of,  422,  434 
deposits  in,  419 
extraction  of  teeth  in,  422 
gouty,  I,  225 

mistaken  for  alveolar  abscess,  433 
percentage  of  cases  of,  438 
pus  in,  diseases  traced  to,  418 
rheumatic,  48,  202,  225,  421 
stimulation  in,  99 
systemic  eflfects  of,  417 
treatment  of,  42  i 
acid,  96 

by  betanaphthol,  59 
by  cresol  and  lysol,  66 
by  emetin,  233 
by  iodin,  58 
by  hthium,  228 
by  mercury  succinimid,  438 
by  ozone,  62 
by  suction,  255 
by  zinc  oxid,  83 
general,  443 
local,  443 
mechanical,  440 
medicinal,  46,  428,  435 
surgical,  423.  43 1 
true,  420,  431 
with  indigestion,  430 
with  neuralgia,  177,  181 
Pyorrhea  astringent,  author's,  117,  429 
Pyorrheal  pockets,  69 


INDEX 


489 


Pyramidon,  148,  450 
Pyrophosphoric  acid,  188 
Pyrotechnics  from  sodium  dioxid,  90 

QUINIDIN,  148 
Quinin,  action  of,  on  blood,  149 
on  white  blood  corpuscles,  366 
as  a  tonic,  150 

as  specific  for  malaria,  150,  450 
bisulphate,  367 
elimination  of,  149 
idiosyncrasy  to,  150 
valerianate,  161 
Quinsy,  205 

RACHITIS,  188,  190 
Radiograph,  value  of,  in  dentistry, 

252,  394 

in  diagnosis,  345,  371,  373,  377 
Radiographs  in  operative  cases,  388 

interpretation  of,  354 

of  nodules,  304 

of  pulpless  tooth,  340 
Radium  salts,  rays  of,  253 
Rarefied  area,  395 
Rash,  boric  acid,  43 

quinin,  150 
Rational  therapeutics,  i 
Ray-fungus,  464 

Rays,  alpha,  beta,  and  gamma,  253 
Reaction  of  boric  acid,  44 

of  saliva,  236 

of  sodium  dioxid,  89  . 
Recession  of  gum,  38,  420,  421 
"Record  blank"  for  narcotics,  133,  136 
Rectum,  medication  by,  26 
Reducing  agents,  93,  405 
Reduction,  process  of,  93 
Reflex  peripheral  irritation,  444 
Refrigerant  agents,  126 
Remedies-,  classes  of,  2 

definitions  of,  30 

desensitizing,  284 

local,  36 

other  than  drugs,  249 

specific,  46 
Research,  institutions  for,  390 
Resins,  derivation  of,  6 

precipitated,  16 

preparations  of,  14 

solubility  of,  274 
Resistance,  vital,  lowered,  444 
Resolution,  3 

promotion  of,  108 
Resorcinol,  59 

Resorption  in  cases  of  abscess,  376,  378 
Respiration,  artificial,  131,  132,  159 
Respiratory  apparatus,  efficiency  of,  175 

centers,  functional  activity  of,  175 

failure,  132 

stimulants,  175 
Restoratives,  34,  178,  181 
Retainer  for  teeth,  440 

wax,  directions  for  making,  440 
Retractor,  use  of,  384 
Rhein's  ionic  theory,  348 

method  of  filling  canals,  341 


Rheumatism,  45 

acute,  48,  225,  229 

salicylic  acid  in,  46 
chronic,  170,  200 
due  to  pyorrheal  infection,  422 
muscular,  no,  iii,  144 
treatment  of,  by  aspirin,  47 
by  salol,  46 
Rhigolene  spray,  128 
Rhizome  of  plants,  7 
Rhubarb,  preparations  of,  213 
Ricinolein,  212 
Ringer  tablet  "B,"  179 
Ring-worm,  59,  199,  214 
Rochelle  salt,  219 
Roe,  Prof.  J.  N.,  468 
Rontgen  ray,  252 
Root  amputation,  139 

-canals,  asepiss  of,  360 
enlargement  of,  90 
filUng  of,  82,  394 

with  chloropercha,  143 
with  various  materials,  394 
gangrenous,  42,  95,  104 
sterilization  of,  104 
tortuous,  90,  95 
treatment  of,  52 
aseptic,  169 
standar  for,  349 
with  thydmocamphen,  115 
cementosed,  446,  447 
decayed,  349 
denuded,  433 
encystment  of,  378 
-end,  denuded,  377,  433 
encapsulated,  398,  401 
filling  of,  386 
infection  of,  445 
roughening  of,  376,  377 
resorption  of,  378 
excision  of,  382,  385,  433 
-filling,  asepsis  in,  396 
old,  removal  of,  346 
pastes,  395 
pus  formation  in,  371 
surface,  exposure  of,  434 
Roots  of  plants,  7 
Rose,  red,  preparations  of,  242 
Rosin,  III 
Rubber  dam,  adjustment  of,  176,  315, 

344,  349.  397.  4o6 
sore  mouth,  75,  79 
Rubefacients,  107 

C  ACCHARIN,  243 

>-5     Sacrifice  of  teeth,  370,  421 

Sal  ammoniac,  234 

SalicyUc  acid,  45 

Saline  cathartics,  216,  366 

Saliva,  change  in,  84 

examination  of,  236,  453 

pus-laden,  swallowing  of,  422 
Salivation,  194,  459,  461 

atropin  for,  176 

effect  of,  on  teeth,  421 

free,  in  pyorrhea,  439 

prevention  of,  226 


490 


INDEX 


Salol,  46 

Salophen,  47 

Salt  action,  133,  215 

solution,  133,  215 

physiologic,  26,  178,  356 
Saltpeter,  227 
Salts,  effervescent,  17 

soluble,  183 
Salvarsan,  99,  195,  202,  456 

contraindications  of,  202 

or  "606,"  202,  456 
Saponin,  203 
Sarsaparilla,  203 

as  alterative  in  syphilis,  203 

compound  syrup  of,  212,  366 
Sarsa-saponin,  203 
Sassafras,  123 

medulla,  239 
Scabies,  45,  59,  214 
Scalds,  37 
Scale  salts,  183 
Scaling,  process  of,  425 

D.  D.  Smith's,  427 
Scar  tissue,  254 

Schreier's  alloy,  use  of,  technic  of,  341 
Scopolamin  hydrobromid,  160 
Sealing,  hermetic,  322,  375,  408 

in  root-canal  work,  400 

in  of  remedies,  300,  359 

of  cavity,  362 

with  cement,  365 
Secretion,  excessive,  expulsion  of,  231 

gastric,  antiseptic  action  of,  417 

glandular,  arrest  of,  72 

of  serum,  372 
Secretions,  control  of,  176 

effects  of  opium  on,  157 
pilocarpin  on,  229 
Sedatives,  35 
Seidlitz  powder,  219 
Senna,  209,  210,  211 
Septicemia,  treatment  of,  by  echafolta, 

204 
Sequestra,  exfoliation  of,  368 

removal  of,  97 
Serous    membranes,    inflammation    of, 

159 
Serum  antidiphthericum,  247 

antipneumococcus,  248 

antistaphylococcus,  248 

antistreptococcus,  248 

antitetanicum,  247 

production  of,  5 

weeping  of,  371 
Serums,  action  of,  247 
"Setting"  of  paste,  312 
Sex,  a  factor  in  dosage,  28 
Shaving  emollient,  75,  79,  117 
Shock,  alcohol  in,  169 

from  anesthetics,  176 

from  hemorrhage,  178 
"Shot-gun"  prescription,  264 
Sialogogues,  35,  236 
Sight,  accidental  loss  of,  425 
Silver  chlorid  precipitate,  470 

metallic,  85 

nitrate,  85 

as  prophylactic,  288 


Silver,  nitrate,  for  babies'  sore  eyes,  86 
neutralizing  of,  275 

preparations  of,  colloidal,  88 

salts,  action  of  sunlight  on,  86,  252, 
288      • 

vitellin,  87 
Sinalbin,  109 
Sinigrin,  109 
Sinus,  apical,  of  bicuspid,  353 

cauterizing  of,  64,  65,  374 

closed,  69 

dento-alveolar,  85 

discharging  for  several  months,  376 

establishment  of,  374,  377 

in  alveolar  abscess,  98,  373 

irrigation  of,  374 

opening  into  mouth,  373 

treatment  of,  by  hydrogen  dioxid, 

69,  374 
by  trichloracetic  acid,  98 

tubercular,  chronic,  85 

weeping  of,  376 
Skin,  hypodermic  injection  through,  24 

inflammation  of,  83,  123 

lesions,  122 
Sleep,  narcotic,  156 
Sleeping  sickness,  457 
Slippery  elm,  123 
Sloughing  of  tissue,  causes  of,  134 

from  arsenic  trioxid,  1 00 
Smallpox  vaccine,  248 
Smokers,  gingivitis  in,  465 

mouths  of,  463 
Snake-bite,  169,  203 
Soap,  incompatabihty  of,  41 

soluble,  407 

white  castile,  40 
Soapstone,  125 
Sockets,  painful,  139 
Soda,  caustic,  poisoning  by,  105 

chlorinated,  92 
Sodium  benzoate,  45 

bicarbonate,  37 

incompatibility  of,  38,  275 
■  borate,  38 

bromid,  155 

dioxid,  89 

as  bleaching  agent,  405,  406,  408 
ice-water  solution  of,  406 

hydroxid,  104 

as  a  by-product,  89 
.  iodid,  193 

ion,  155 

peroxid,  89 

phenolsulphonate,  344 

phosphate,  218 

pyroborate,  38 

salicylate,  48 

sulphate,  217,  344 
Solids,  mixtures  of,  16 
Solutions,  9 

anesthetizing,  279,  317 

antiseptic,  271,  311,  316 

bichlorid  of  mercury,  198 

concentration  of,  216 

cudbear,  425,  427 

Dakin's,  179 

disclosing,  428 


INDEX 


491 


Solutions,  emetin  hydrochlorid,  436 

Fehling's,  471 

hyperchlorous  acid,  179 

hyperisotonic,  216 

hypertonic,  179 

isotonic,  133,  179,  216 

magnesium  sulphate,  217 

of  non-volatile  substances,  9 

percentage  in,  263 

pharmaceutic,  8 

prescriptions  for,  practical,  271 

rosin,  iii 

salt,  26,  133,  178,  215,  356 

sodium  bicarbonate,  433 

sodium  dioxid,  89 

true,  18 
Solvent,  chloroform  as,  143 

eucalyptol  as,  396,  397 
Somnifacients,  34,  150 
Somnoform,  127 
Sores,  open,  60 
Spanish  fly,  112 
Spasms,  relaxation  of,  174 
Spearmint,  238 
Specific  disease,  2,  455 

gravity,  257,  468 

remedy,  2,  150,  202 
Spinal  cord  depressants,  154 
Spirillum,  affections  due  to,  202 
Spirits,  10,  166 

aromatic,  10 

of  ether,  compound,  142 

of  mindererus,  230 

of  nitrous  ether,  230 
Spirocheta  in  pyorrhea!  pus,  417 

_  pallida,  195,  455,  457 
Splints  for  teeth,  21,  440 
Spooner,  use  of  arsenic  by,  102,  325 
Spore  formation,  277 
Sprains,  61,  75,  144 
Spray,  alcohol,  368,  448 

cinnamon,  50 

cocain,  133 

ether,  142,  286 

ethyl  chlorid,  250 

rhigolene,  128 
Spraying  outfits,  428 
Sputum  of  consumptives,  462 
Squill,  preparations  of,  235 
Stain  from  silver  nitrate,  87 

ineradicable,  330 

nitric  acid,  96 

removal  of,  321 
Staining  agent,  75 
Staphylococcus  pyogenes,  364 

aureus,  245 
Starch,  118 

Starvation,  deficiency  of  fat  in,  191 
Steapsin,  206 
Stearoptenes,  6,  53 
Sterilization  by  sublamin,  201 

dental,  277,  397 

by  chemic  agents,  278 

by  direct  flame,  277 

by  dry  and  moist  heat,  71,  278 

by  f ormaldehyd,  294,  '295 

by  ionization,  348 

in  pulp  removal,  315 


Sterilization,  mechanical,  328 

of  dentin,  199,  310 

of  fingers,  317 

of  hypodermic  syringe,  24 

of  instruments,  38,  71,  201,  278,383 
397.  426 

responsibility  for,  280 

surgical,  41 
Sterilizers,  71,  278 

Stewart,  Dr.  Lee  K.,  appliances  of,  441 
Stimulants,  35,  163 

cardiac,  163 

gastric,  177 

respiratory,  175    , 

restorative,  ,178 
Stings,  118 
Stock  solutions,  279 
Stomach,  absorption  of  drugs  in,  22 

disorders  of,  206 

hyperacidity  of,  38,  40 

irritant  material  in,  233 

-pump,  dangers  of,  97 

rupture  of,  97 

washing  of,  123 
Stomachics,  177 
Stomatitis,  argyrol  in,  87 

chronic,  86 

mercurial,  194,  226,  272,  461 

treatment  of,  39,  52,  55,  82,  194 

ulcerative,  51,  59,  61,  80,  81,  83, 
204 
Stopping,  temporary,  use  of,  365 
Streptococcus  decomposition,  340 

fecalis,  357 

infection,  68 

pyogenes,  364 
longus,  419 

pyorrhea!,  in  feces,  417 

salivarius,  357 

vaccine,  248 

viridans,  245,  340,  357 
in  pyorrhea,  417,  418 
Strontium  iodid,  193 
Strychnin,  164 

as  alkaloid  of  nux  vomica,  163 

physiological  action  of,  164 

poisoning,  164,  174 
diagnostic  sign  in,  165 
sedatives  in,  151 
treatment  of,  165 

therapeutics  of,  165 

value  of,  in  poisoning  by  depres- 
sants, 165 
Stupe,  turpentine,  iii 
Styptics,  35,  72 
Sublamin,  200 
"Submarine  gardens,"  55 
Succinic  dioxid,  91 

Suction,  hyperemia  produced  by,  254 
Sudorifi.cs,  32,  228 
Sugar  of  milk,  243 

Suggestion  in  treatment  of  disease,  255 
Sulphonal,  hypnotic  action  of,  152 

poisoning  by,  152 
Sulphonmethane,  152 
Sulphur,  action  of,  physiologic,  214 

in  parasitic  diseases,  214 

lotum,  214 


492 


INDEX 


Sulphur,poisoning  in  match  factories,  187 
precipitated,  214 
sublimatum,  214 
Sulphurated  calcium,  204 
Sulphuric  acid,  94,  340 

action  of,  corrosive,  344 

free,  in  phenolsulphonic  acid,  375 

in  pulp  removal,  316 

in  treatment  of  pulpless  teeth, 

343 
therapeutics  of,  95 
Sulphurous  acid,  31,  32,  93,  214 
Sunlight,  eflFect  of,  on   silver  salts,  86, 

252,288 
Suppositories,  19 
glycerin,  117 
Suppuration,  arrest  of,  205 

in  wounds,  59 
Suppurative  pericementitis,  364 
Suprarenal  gland,  I'j 
Suprarenin,  77 

Surgery  in  alveolar  abscess,  382 
in  antral  diseases,  413 
major,  nitrous  oxid  in,  141 
Sweat,  clammy,  249 

glands,  activity  of,  229 
Sweating,  excessive,  169 
Sweet  oil,  118 

Swelling  due  to  abscesses,  355 
Sylvester's    artificial    respiration,    132, 

Syncope,  115,  169,  173 
Synthetic  drugs,  5 

substitutes  for  cocain,  136 
Syphilis  2,  455 

cure  of,  460 

diagnosis  of,  certain,  459 

differentiated  from  gingivitis,  465 

germ  of,  455 

infection  of,  459 

prmiary,  456 

diagnosis  and  treatment  of,  456 

secondary,  192,  195,  226,  458 
diagnosis  and  treatment  of,  458 

specific  for,  202,  460 

symptoms  of,  455 

tertiary,  200,  460 

potassium  iodid  in,  192 

treatment  of,  by  arsenic,  99 
by  merciuy,  195,  199,  200 
by  "606,"  195 
Syphilitic  conditions,  iron  iodid  in,  186 

mucous  patches,  458 
Syringe  for  phenolsulphonic  acid,  381 
Syrups,  10 
Systemic  diseases,  origin  of,  248 

y  ABLETS,  18 
•^  alcresta  ipecac,  232 

corrosive  sublimate,  18,  198 
Ringer,  179 
Talc,  purified,  124 
Tamarind,  209 
Tannic  acid,  31,  72,  74,  329 

in  krameria,  74 

use  of,  objections  to,  329 
Tartar  emetic,  233 

solvent,  436 


Teeth,  anesthetization  of,  129 

artificial,  436 

bleaching  of,  70,  88,  90,  93,  98,  190, 
403 

bridged,  295,  303,  443 

care  of,  358,  429 

cleanliness  of,  459 

coalescing  of,  446 

discoloration  of,  320,  402,  407 

dropping  out  of,  420 

erosion  of,  40 

eruption  of,  145 

examination  of,  in  match  factories, 
187 

exfoliation  of,  326 

extraction  of,  74,  120,  127 
needless,  370,  421 
painless,  133,  136 

fracture  of,  252 

impacted,  445,  446 

loose,  in  pyorrhea,  421,  422 
support  for,  442 

lost,  replacing  of,  442 

pink  staining  of,  402 

replantation  of,  435 

scahng  of,  64,  425 

shortening  of,  442 

sound,  extraction  of,  447 

whitening  of,  70 
Temperature,  fever,  reduction  of,  145, 
169 

influence  of,  29 
Terebene,  112 
Terpenes,  6 
Test,  chemic,  for  sodium  dioxid,  406 

heat,  468 

nitric  acid,  468 
Tetanus,  convulsions  of,  151,  174 

distinguished  from  strychnin  poi- 
soning, 165 

toxins  of,  245,  246 
Tetra-iodo-phenol-phthalein,  56 
Tetra-iodo-pyrrol,  56 
Thebain,  156 
Theobroma,  129 
Therapeutics,  definition  of,  i 

practical,  281 

preventive,  300 
Therapy,  successful,  281 
Thermal  sensitiveness,  283,  284,  294 
Thermometric  scale,  250 
Thirst,  allaying  of,  189 
Throat,  diseases  of,  210 
Throat,  sore,  74,  75,  81,  82,  98,  122,  123 

putrid,  70 
Thrush,  38 

treatment  of,  39,  70 
Thyme,  oil  of,  54 
Thymocamphen,  55,  115 
Thymol,  action  of,  54,  311 

in  eucalyptol,  124 

iodid,  56 
Thymophen,  55 
Thyroid  glands,  desiccated,  78 
Tic  douloureux,  therapeutics  of, '45 1, 452 
Tincture  of  opium,  camphorated,' 157 
Tinctures,  assay  of,  13 

use  of,  by  dentists,  14 


INDEX 


493 


Tissue  in  cavity,  nature  of,  331 

laceration  of,  134 

waste,  204 
Tissues  after  cauterization,  346 

constringing  of,  429 
.  of  mouth,  hard,  283 

not  associated  with  the  teeth,  453 
soft,  453 

sloughing  of,  134 
Tobacco,  162 
Tolerance  of  drugs,  27 
Toluene,  243 
Tongue,  cancer  of,  70 
Tonics,  35,  181 

quinin,  150 

spring,  123,  240 
TonsilUtis,  follicular,  205 
Tonsils,  enlarged,  81 
Tooth,  anatomic  structure  of,  285 

bacterial  growth  on,  427 

-pastes,  base  of,  37 
for  pyorrhea,  429 

powders,  base  of,  37 
for  general  use,  270 

♦structure,  disinfection  of,  279 
exposed,  86 
sterilization  of,  277 

vital,  opening  of,  392 
Toothache  during  devitalization,  327 

jumping,  313 

relief  of,  by  chewing  tobacco,  163 

treatment  of,  67,  307 
Toxicology,  definition  of,  1,2 
Toxins,  absorption  of,  417 

extracellular,  245,  418 

in  digestive  tract,  453 

in  pulp  decomposition,  337 

intracellular,  245 
Tragacanth,  121 

Trauma  a  cause  of  antral  disease,  412 
Trichloracetic  acid,  33,  98,  288 
Tricresol,  65,  338 
Trifacial  neuralgia,  444 
Trigeminal  neuralgia,  444 
Trional,  153 

Trioxymethylen,  67,  288 
Troches,  17,  75 

ammonium  chlorid,  234 

tannic,  acid,  73 
Tropacocain  hydrochlorid,  136 
Troy  weight,  257,  258 
Trypsin,  206 
Tubercle    bacillus,    entrance    of,    into 

body,  462 
Tuberculosis,  462 

cod-liver  oil  in,  191  - 

pulmonary,  67,  202 

treatment  of,  200,  203,  462 
Tumor,  apical,  388 
Turpentine,  no,  in 
Typhoid  fever,  intestinal  antiseptic  in, 

91 

vaccine,  248 

T  TLCERATION,  lupous,  99,  454 
^         tuberculous,  99,  462 
Ulcers,  59,  83,  86,  147 


Ulcers,  chancrous,  454 

duodenal,  38 

dusting  powder  for,  125 

gastric,  38 

gingival,  465 

in  the  mouth,  454 

indolent,  77,  79,  80,  98,  103 

phagedenic,  96 

sluggish,  57 

syphiUtic,  59,  197,  454,  456 

tubercular,  462 
United  States  Pharmacopeia,  IX,  3 

previous  to  1880,  257 
Urea  hydrochlorid  and  quinin,  150 

nitrate  precipitate,  469 
Uremia,  acute,  229 

convulsions  in,  174 

distingmshed  from  alcoholism,  167 
Uric  acid  precipitate,  469 
Urine,  albumin  in,  443 

alkaUnity  of,  223,  225 

analysis  of,  471 

chlorids  in,  469 

effects  of  potassium  on,  225 

examination  of,  468 

mercury  in,  194 

phosphates  in,  470 

reaction  of,  468 

secretion  of,  223,  225 

solids  of,  468,  469 

specific  gravity  of,  468 

sugar  in,  443,  470 

sulphates  in,  470 

urates  in,  469 

urea  in,  469 
Urotropin,  68 


VACCINES,  autogenous,  5,  248 
mixed  and  stock,  248 
use  of,  in  pyorrhea,  439 
Valerianic  acid,  180 
Vallet's  mass,  185 
Vanilla,  242 
Vasehn,  liquid,  120 
Vault  of  mouth  in  abscess  cases,  380 
Vegetable  drugs,  5,  7 
Vehicles  for  drugs,  17,  18,  19 
Vein,  air  injected  into,  23 
Venous  hyperemia,  307 
Vesicants,  107 
Vesication,  250 
Vibrating  coil,  338 
Vinegars,  13 
Vital  pulp,  removal  of,  314 

resistance,  lowered,  444 
Vitality  of  tooth  after  desensitizing,  297 
Vitriol,  white,  81 

green,  183 
Volatile  oils,  48  _ 

prunus  virginanai,  178 
valerian,  180 

substances,  solutions  of,  9,  10 
Volume  of  drugs,  14,  16 
Vomiting  induced  by  apomorphin,  231 

lime-water  for,  37 
Vital  resistance,  lowering  of,  444 


494 


INDEX 


WARTS,  removal  of,  46,  96,  98 
Washed  sulphur,  214 
Wassermann  reaction,  456 
Waters,  aromatic  and  medicated,  9 
Wax  models,  441 
Weight  of  drugs,  15,  16 
Weights  and  measures,  English,  equiva- 
lents to,  261 
Whooping-cough,  59,  145,  151 
Wild  cherry,  syrup  of,  178 
Wine  measure,  258 
Wines,  12,  166 
Wires,  diagnostic,  351,  353 
Witch-hazel,  75 
Wood  charcoal,  60 
Wool  fat,  purified,  1 20 
Wounds,  aseptic,  123 

healing  of,  60 

incised,  73 

infected,  179,  252 

lacerated,  73 

packing  of,  85,  386 

painful,  139 

protected  by  gutta-percha,  124 

sloughing,  59,  103 


Wright's  hypertonic  solution,  179 

V-RAYS  in  diagnosis  of  abscess,  370, 
^^  382 

of  neuralgia,  445 
of  pulpless  teeth,  351,  354 
in  disease  of  antrum,  412 
in  root-canal  work,  400 
in  therapeutics,  252 
Xylene,  346 
Xylol,  346,  351,  352 

VELLOW  cinchona,  148 
*■     Yerba  santa,  366 

ZINC  chlorid  as  a  dangerous  caustic, 
83 
in  treatment  of  cavity,  287 
iodid,  83 

ointment  with  calomel,  197 
oxid,  82,  312 
phenolsulphonate,  82 
sulphate,  81 
sulphocarbolate,  82 


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